(De)coding a technopolity: tethering the civic blockchain to political transformation

This study rests at the intersection of technopolitics, translocal networks and political change. The overall aim of the thesis is to understand, and in turn, influence, the way technology interacts with political transformation. It responds to the fact that social science has thus far neglected to adequately account for and analyze how emerging technologies like blockchain and civic tech influence the way politics is practiced. The main research question guiding the study is how does the design, implementation and use of technopolitical innovations influence the practice of politics. The thesis foregrounds the idea that technopolitical experiments personify a ‘prefigurative politics by design’ i.e. they embody the politics and power structures they want to enable in society. Conducted as part of the EU-funded SUSPLACE project that explores the transformative capacity of sustainable place-shaping practices, the research was predominantly inspired by a hybrid digital ethnography methodology. The thesis confines its focus to three empirical clusters: technopolitical blockchain projects, government-led blockchain projects and place-based civic engagement technologies. The study delineates how differing politico-social imaginaries play a role in the design and implementation of technopolitical projects; addresses contemporary post-political phenomena such as the depoliticization of agency; and identifies the activation of a place-based geography of political action through digitally-mediated municipal networks. It articulates the language and frameworks necessary to analyze these present-day challenges, while simultaneously developing approaches that can be exported to different domains of political activism. Technology is not neutral; but neither are its designers and users. The thesis finds that it is through considerable, deliberate efforts, in conjunction with individual and collective choices, that technopolitical innovations can reframe our socio-economic and political realities. The study demonstrates the emphatic and urgent need for researchers, practitioners, politicians and citizens to collaboratively work on redrawing boundaries of access, empowering the citizenry, creating new forms of organization and re-politicizing the economy. It outlines a transdisciplinary research and practice agenda that aims at not only (de)coding the existing technopolitical innovations, but also (re)coding them to create a more equitable system of politics. The thesis concludes that since coding affordances and constraints in a technopolitical system is shown to regulate political agency and even influence the behavior of citizens, we must devise value-driven technology that incentivizes creating a more equitable political system.&nbsp

The political imaginaries of blockchain projects: discerning the expressions of an emerging ecosystem

There is a wealth of information, hype around, and research into blockchain’s ‘disruptive’ and ‘transformative’ potential concerning every industry. However, there is an absence of scholarly attention given to identifying and analyzing the political premises and consequences of blockchain projects. Through digital ethnography and participatory action research, this article shows how blockchain experiments personify ‘prefigurative politics’ by design: they embody the politics and power structures which they want to enable in society. By showing how these prefigurative embodiments are informed and determined by the underlying political imaginaries, the article proposes a basic typology of blockchain projects. Furthermore, it outlines a frame to question, cluster, and analyze the expressions of political imaginaries intrinsic to the design and operationalization of blockchain projects on three analytic levels: users, intermediaries, and institutions.</p

Prefigurative Post-Politics as Strategy:The Case of Government-Led Blockchain Projects

Critically engaging with literature on post-politics, blockchain and algorithmic governance, and drawing also on knowledge gained from undertaking a three-year empirical study, the purpose of this article is to better understand the transformative capacity of government-led blockchain projects. Analysis of a diversity of empirical material, which was guided by a digital ethnography approach, is used to support the furthering of the existing debate on the nature of the post-political as a condition and/or strategy. Through these theoretical and empirical explorations, the article concludes that while the post-political represents a contingent political strategy by governmental actors, it could potentially impose an algorithmically enforced post-political ‘condition’ for the citizen. It is argued that the design, features and mechanisms of government-led projects are deliberately and strategically used to delimit a citizens’ political agency. In order to address this scenario, we argue that there is a need not only to analyse and contribute to the algorithmic design of blockchain projects (i.e. the affordances and constraints they set), but also to the metapolitical narrative underpinning them (i.e. the political imaginaries underlying the various government-led projects)

Decentralizing Geographies of Political Action:Civic tech and Place-Based Municipalism

This article introduces the concept of ‘place-based civic tech’ — citizen engagement technology codesigned by local government, civil society and global volunteers. It investigates to what extent creating such a digital space for autonomous self-organization allows for the emergence of a parallel, self-determining and more place-based geography of politics and political action. It finds that combining online tools with offline collaborative practices presents a unique opportunity for decentralization of power and decision-making in a manner which both politically motivates civil society and begins to update the infrastructure of democracy. The discussion is supported by a combination of primary and secondary data, with research methods including ethnographic and participatory observation techniques. Research data is drawn from a range of empirical sources, including an in-depth case study of the radical municipalist movement in Spain. The article concludes that there is a clear and compelling narrative of cities taking power back, in the form of a plural and globally networked movement. As such, this study contributes to both the theory and practice of civic tech, collective impact, municipalism and place-based urban politics while emphasizing the need for further research on experiments and movements currently existing below the academic radar

Effects of a high-dose 24-h infusion of tranexamic acid on death and thromboembolic events in patients with acute gastrointestinal bleeding (HALT-IT): an international randomised, double-blind, placebo-controlled trial

Background: Tranexamic acid reduces surgical bleeding and reduces death due to bleeding in patients with trauma. Meta-analyses of small trials show that tranexamic acid might decrease deaths from gastrointestinal bleeding. We aimed to assess the effects of tranexamic acid in patients with gastrointestinal bleeding. Methods: We did an international, multicentre, randomised, placebo-controlled trial in 164 hospitals in 15 countries. Patients were enrolled if the responsible clinician was uncertain whether to use tranexamic acid, were aged above the minimum age considered an adult in their country (either aged 16 years and older or aged 18 years and older), and had significant (defined as at risk of bleeding to death) upper or lower gastrointestinal bleeding. Patients were randomly assigned by selection of a numbered treatment pack from a box containing eight packs that were identical apart from the pack number. Patients received either a loading dose of 1 g tranexamic acid, which was added to 100 mL infusion bag of 0·9% sodium chloride and infused by slow intravenous injection over 10 min, followed by a maintenance dose of 3 g tranexamic acid added to 1 L of any isotonic intravenous solution and infused at 125 mg/h for 24 h, or placebo (sodium chloride 0·9%). Patients, caregivers, and those assessing outcomes were masked to allocation. The primary outcome was death due to bleeding within 5 days of randomisation; analysis excluded patients who received neither dose of the allocated treatment and those for whom outcome data on death were unavailable. This trial was registered with Current Controlled Trials, ISRCTN11225767, and ClinicalTrials.gov, NCT01658124. Findings: Between July 4, 2013, and June 21, 2019, we randomly allocated 12 009 patients to receive tranexamic acid (5994, 49·9%) or matching placebo (6015, 50·1%), of whom 11 952 (99·5%) received the first dose of the allocated treatment. Death due to bleeding within 5 days of randomisation occurred in 222 (4%) of 5956 patients in the tranexamic acid group and in 226 (4%) of 5981 patients in the placebo group (risk ratio [RR] 0·99, 95% CI 0·82–1·18). Arterial thromboembolic events (myocardial infarction or stroke) were similar in the tranexamic acid group and placebo group (42 [0·7%] of 5952 vs 46 [0·8%] of 5977; 0·92; 0·60 to 1·39). Venous thromboembolic events (deep vein thrombosis or pulmonary embolism) were higher in tranexamic acid group than in the placebo group (48 [0·8%] of 5952 vs 26 [0·4%] of 5977; RR 1·85; 95% CI 1·15 to 2·98). Interpretation: We found that tranexamic acid did not reduce death from gastrointestinal bleeding. On the basis of our results, tranexamic acid should not be used for the treatment of gastrointestinal bleeding outside the context of a randomised trial

Effects of hospital facilities on patient outcomes after cancer surgery: an international, prospective, observational study

Background Early death after cancer surgery is higher in low-income and middle-income countries (LMICs) compared with in high-income countries, yet the impact of facility characteristics on early postoperative outcomes is unknown. The aim of this study was to examine the association between hospital infrastructure, resource availability, and processes on early outcomes after cancer surgery worldwide.Methods A multimethods analysis was performed as part of the GlobalSurg 3 study-a multicentre, international, prospective cohort study of patients who had surgery for breast, colorectal, or gastric cancer. The primary outcomes were 30-day mortality and 30-day major complication rates. Potentially beneficial hospital facilities were identified by variable selection to select those associated with 30-day mortality. Adjusted outcomes were determined using generalised estimating equations to account for patient characteristics and country-income group, with population stratification by hospital.Findings Between April 1, 2018, and April 23, 2019, facility-level data were collected for 9685 patients across 238 hospitals in 66 countries (91 hospitals in 20 high-income countries; 57 hospitals in 19 upper-middle-income countries; and 90 hospitals in 27 low-income to lower-middle-income countries). The availability of five hospital facilities was inversely associated with mortality: ultrasound, CT scanner, critical care unit, opioid analgesia, and oncologist. After adjustment for case-mix and country income group, hospitals with three or fewer of these facilities (62 hospitals, 1294 patients) had higher mortality compared with those with four or five (adjusted odds ratio [OR] 3.85 [95% CI 2.58-5.75]; p&lt;0.0001), with excess mortality predominantly explained by a limited capacity to rescue following the development of major complications (63.0% vs 82.7%; OR 0.35 [0.23-0.53]; p&lt;0.0001). Across LMICs, improvements in hospital facilities would prevent one to three deaths for every 100 patients undergoing surgery for cancer.Interpretation Hospitals with higher levels of infrastructure and resources have better outcomes after cancer surgery, independent of country income. Without urgent strengthening of hospital infrastructure and resources, the reductions in cancer-associated mortality associated with improved access will not be realised

Effectiveness of a national quality improvement programme to improve survival after emergency abdominal surgery (EPOCH): a stepped-wedge cluster-randomised trial

Background: Emergency abdominal surgery is associated with poor patient outcomes. We studied the effectiveness of a national quality improvement (QI) programme to implement a care pathway to improve survival for these patients. Methods: We did a stepped-wedge cluster-randomised trial of patients aged 40 years or older undergoing emergency open major abdominal surgery. Eligible UK National Health Service (NHS) hospitals (those that had an emergency general surgical service, a substantial volume of emergency abdominal surgery cases, and contributed data to the National Emergency Laparotomy Audit) were organised into 15 geographical clusters and commenced the QI programme in a random order, based on a computer-generated random sequence, over an 85-week period with one geographical cluster commencing the intervention every 5 weeks from the second to the 16th time period. Patients were masked to the study group, but it was not possible to mask hospital staff or investigators. The primary outcome measure was mortality within 90 days of surgery. Analyses were done on an intention-to-treat basis. This study is registered with the ISRCTN registry, number ISRCTN80682973. Findings: Treatment took place between March 3, 2014, and Oct 19, 2015. 22 754 patients were assessed for elegibility. Of 15 873 eligible patients from 93 NHS hospitals, primary outcome data were analysed for 8482 patients in the usual care group and 7374 in the QI group. Eight patients in the usual care group and nine patients in the QI group were not included in the analysis because of missing primary outcome data. The primary outcome of 90-day mortality occurred in 1210 (16%) patients in the QI group compared with 1393 (16%) patients in the usual care group (HR 1·11, 0·96–1·28). Interpretation: No survival benefit was observed from this QI programme to implement a care pathway for patients undergoing emergency abdominal surgery. Future QI programmes should ensure that teams have both the time and resources needed to improve patient care. Funding: National Institute for Health Research Health Services and Delivery Research Programme

Effectiveness of a national quality improvement programme to improve survival after emergency abdominal surgery (EPOCH): a stepped-wedge cluster-randomised trial

BACKGROUND: Emergency abdominal surgery is associated with poor patient outcomes. We studied the effectiveness of a national quality improvement (QI) programme to implement a care pathway to improve survival for these patients. METHODS: We did a stepped-wedge cluster-randomised trial of patients aged 40 years or older undergoing emergency open major abdominal surgery. Eligible UK National Health Service (NHS) hospitals (those that had an emergency general surgical service, a substantial volume of emergency abdominal surgery cases, and contributed data to the National Emergency Laparotomy Audit) were organised into 15 geographical clusters and commenced the QI programme in a random order, based on a computer-generated random sequence, over an 85-week period with one geographical cluster commencing the intervention every 5 weeks from the second to the 16th time period. Patients were masked to the study group, but it was not possible to mask hospital staff or investigators. The primary outcome measure was mortality within 90 days of surgery. Analyses were done on an intention-to-treat basis. This study is registered with the ISRCTN registry, number ISRCTN80682973. FINDINGS: Treatment took place between March 3, 2014, and Oct 19, 2015. 22 754 patients were assessed for elegibility. Of 15 873 eligible patients from 93 NHS hospitals, primary outcome data were analysed for 8482 patients in the usual care group and 7374 in the QI group. Eight patients in the usual care group and nine patients in the QI group were not included in the analysis because of missing primary outcome data. The primary outcome of 90-day mortality occurred in 1210 (16%) patients in the QI group compared with 1393 (16%) patients in the usual care group (HR 1·11, 0·96-1·28). INTERPRETATION: No survival benefit was observed from this QI programme to implement a care pathway for patients undergoing emergency abdominal surgery. Future QI programmes should ensure that teams have both the time and resources needed to improve patient care. FUNDING: National Institute for Health Research Health Services and Delivery Research Programme

Development and validation of parental vaccine attitudes scale for use in low-income setting

Background: This study aimed to develop a tool and assess its validity to measure childhood vaccine related attitudes among parents in a low-income setting.Methods: We developed a vaccine attitudes scale (VAS) composed of 14 Likert items each with 5 responses ranging from strongly agree to strongly disagree (sum of scores range 14-70). The tool was administered to 901 parents with children 4-12 months of age during a vaccine coverage survey in Sindh, Pakistan. We performed factor analysis with eigenvalues \u3e0.3 for sufficient factor loading and calculated Cronbach alpha for reliability.Results: The mean ± SD score on VAS was 48 ± 3 and Cronbach alpha was 0.61. Factor analysis identified that VAS measured 2 different domains related to the childhood vaccine related attitudes; (1) 10 items related to vaccine perceptions and concerns (mean 40 ± 5.5; Cronbach alpha 0.95) and (2) 4 items related to vaccine preventable disease salience and community benefit (mean 7 ± 3; Cronbach alpha 0.97). The odds of children being unimmunized was 5 times higher among parents who scored high (13-20) as compared with low (\u3c13) on the subscale related to disease salience and community benefit (odds ratio 5.2; 95% CI: 3.6-7.6). The odds of children being unimmunized was 1.5 times higher among parents scoring high (40-50) as compared with low (\u3c40) on subscale related to vaccine perception/concerns (odds ratio 1.5; 95% CI: 1.1-2.2).Conclusion: The 4-item scale assessing parental attitudes toward vaccine preventable disease salience and community benefit is sufficiently reliable and can predict vaccine acceptance among parents in low income setting

Reasons for non-vaccination and incomplete vaccinations among children in Pakistan

Background: Global immunization efforts have received a boost through the introduction of several new vaccines. These efforts however, are threatened by sub-optimal vaccine coverage, particularly in countries with large birth cohorts. Pakistan has one of the largest birth cohorts in the world, where coverage of routine vaccination remains persistently inadequate. We undertook this study to ascertain reasons for non-vaccination or incomplete vaccination of children less than two years in 8 districts of southern Pakistan.Methods: A cross-sectional survey using WHO recommended rapid coverage assessment technique was conducted in 2014. Using probability proportional to size method, we sampled 8400 households with eligible children (aged 4–12 months). Using a structured questionnaire, mothers or other primary caregivers were interviewed to determine vaccination status of an index child. In case of non-vaccination or incomplete vaccination, respondents were asked for reasons leading to low/no vaccine uptake.Results: Based on both vaccination record and recall, only 30.8% of children were fully vaccinated, 46% had an incomplete vaccination status while 23%were non-vaccinated. The most frequently reported reasons for non-vaccination included: mothers/caregivers being unaware of the need for vaccination (35.3%), a fear of side effects (23%), mother/caregiver being too busy (16.6%), distance from vaccination centers (13.8%), and non-availability of either vaccinators or vaccines at vaccination centers (10.7%).Reasons identified for incomplete vaccination were similar, with caregivers being unaware of the need for subsequent doses (27.3%), non-availability of vaccinators or vaccines (17.7%), mother/caregiver being too busy (14.8%), fear of side effects (11.2%), and postponement for another time (8.7%).Conclusion: Various factors result in non-compliance with vaccination schedules and vaccine refusal within the surveyed communities, ranging from lack of knowledge to non-availability of supplies at vaccination centers. These barriers are best addressed through multi-pronged strategies addressing supply gaps, increasing community awareness and enhancing demand for routine vaccination services