How should we write about markets? What responsibilities does this writing bring upon us?This paper offers an immanent critique of 'market studies' scholarship, and through this a call to reflection and reformed action. Turning the intellectual framework of market studies upon itself, we come to see its texts as performative and agential. We discuss these qualities and the associated responsibilities via a reading of literature from the domain of ethnography. An auto-ethnographic sketch of market writing allows us to consider the problematic nature of expertise for market studies scholars and the agency and power of our texts. We find a dual moment of performativity from which our texts emerge more powerful than their authors. On this basis we offer a vision of critical interventions embedded in our texts, underpinned by the intellectual axioms of the market studies program.
Background Over-the-counter antibiotic access is common in low-and-middle-income countries and this may accelerate antimicrobial resistance. Our study explores critical aspects of the drug seller–client interaction and antibiotic dispensing patterns for simulated COVID-19 symptoms during the pandemic in two study sites in Tanzania and Uganda, countries with different government responses to the pandemic. Methods Research assistants posing as clients approached different types of drug sellers such as pharmacies (Pharms), drug shops (DSs), and accredited drug dispensing outlets (ADDOs) in Mwanza, Tanzania (nPharms = 415, nADDOs = 116) and Mbarara, Uganda (nPharms = 440, nDSs = 67), from June 10 to July 30, 2021. The mystery clients held no prescription and sought advice for simulated COVID-19 symptoms from the drug sellers. They documented the quality of their interaction with sellers and the type of drugs dispensed. Results Adherence to COVID-19 preventive measures and vigilance to COVID-19 symptoms was low in both sites but significantly higher in Uganda than in Tanzania. A higher percentage of drug sellers in Mbarara (Pharms = 36%, DSs = 35%, P-value = 0.947) compared to Mwanza (Pharms = 9%, ADDOs = 4%, P-value = 0.112) identified the client’s symptoms as possibly COVID-19. More than three-quarters of drug sellers that sold prescription-only medicines in both Mbarara (Pharms = 86%, DSs = 89%) and Mwanza (Pharms = 93%, ADDOs = 97%) did not ask the MCs for a prescription. A relatively high percentage of drug sellers that sold prescription-only medicines in Mwanza (Pharms = 51%, ADDOs = 67%) compared to Mbarara (Pharms = 31%, DSs = 42%) sold a partial course without any hesitation. Of those who sold antibiotics, a higher proportion of drug sellers in Mbarara (Pharms = 73%, DSs = 78%, P-value = 0.580) compared to Mwanza (Pharms = 40% ADDOs = 46%, P-value = 0.537) sold antibiotics relevant for treating secondary bacterial infections in COVID-19 patients. Conclusion Our study highlights low vigilance towards COVID-19 symptoms, widespread propensity to dispense prescription-only antibiotics without a prescription, and to dispense partial doses of antibiotics. This implies that drug dispensing related to COVID-19 may further drive AMR. Our study also highlights the need for more efforts to improve antibiotic stewardship among drug sellers in response to COVID-19 and to prepare them for future health emergencies.
Background A key factor driving the development and maintenance of antibacterial resistance (ABR) is individuals’ use of antibiotics (ABs) to treat illness. To better understand motivations and context for antibiotic use we use the concept of a patient treatment-seeking pathway: a treatment journey encompassing where patients go when they are unwell, what motivates their choices, and how they obtain antibiotics. This paper investigates patterns and determinants of patient treatment-seeking pathways, and how they intersect with AB use in East Africa, a region where ABR-attributable deaths are exceptionally high. Methods The Holistic Approach to Unravelling Antibacterial Resistance (HATUA) Consortium collected quantitative data from 6,827 adult outpatients presenting with urinary tract infection (UTI) symptoms in Kenya, Tanzania, and Uganda between February 2019- September 2020, and conducted qualitative in-depth patient interviews with a subset (n = 116). We described patterns of treatment-seeking visually using Sankey plots and explored explanations and motivations using mixed-methods. Using Bayesian hierarchical regression modelling, we investigated the associations between socio-demographic, economic, healthcare, and attitudinal factors and three factors related to ABR: self-treatment as a first step, having a multi-step treatment pathway, and consuming ABs. Results Although most patients (86%) sought help from medical facilities in the first instance, many (56%) described multi-step, repetitive treatment-seeking pathways, which further increased the likelihood of consuming ABs. Higher socio-economic status patients were more likely to consume ABs and have multi-step pathways. Reasons for choosing providers (e.g., cost, location, time) were conditioned by wider structural factors such as hybrid healthcare systems and AB availability. Conclusion There is likely to be a reinforcing cycle between complex, repetitive treatment pathways, AB consumption and ABR. A focus on individual antibiotic use as the key intervention point in this cycle ignores the contextual challenges patients face when treatment seeking, which include inadequate access to diagnostics, perceived inefficient public healthcare and ease of purchasing antibiotics without prescription. Pluralistic healthcare landscapes may promote more complex treatment seeking and therefore inappropriate AB use. We recommend further attention to healthcare system factors, focussing on medical facilities (e.g., accessible diagnostics, patient-doctor interactions, information flows), and community AB access points (e.g., drug sellers).
Background A key factor driving the development and maintenance of antibacterial resistance (ABR) is individuals’ use of antibiotics (ABs) to treat illness. It is therefore crucial to understand the dynamics of patient treatment-seeking - where patients go when unwell, what motivates choice, and treatments they obtain. Developing a better understanding of social inequalities of antibiotic use in low resource settings has been identified as a research priority, as has understanding pluralistic healthcare landscapes, but so far robust multi-country mixed methods data has been lacking. This paper aims to investigate patterns and determinants of patient treatment-seeking pathways, and how they intersect with AB use in East Africa, a region where ABR-attributable deaths are exceptionally high. MethodsThe Holistic Approach to Unravelling Antimicrobial Resistance (HATUA) Consortium collected quantitative data from 6,827 adult outpatients presenting with urinary tract infection (UTI) symptoms in Kenya, Tanzania, and Uganda, and conducted qualitative in-depth patient interviews with a subset (n=116). We described patterns of treatment-seeking visually using Sankey plots and elucidated explanations using mixed-methods. Using Bayesian hierarchical regression modelling, we investigated the associations between socio-demographic, economic, healthcare, and attitudinal factors and three outcomes related to ABR: self-treatment as a first step, having a multi-step treatment pathway, and consuming ABs.ResultsDespite patients predominantly seeking help from medical facilities as a first step, many described complex and repetitive treatment-seeking pathways, which increased the likelihood of consuming ABs. Higher socio-economic status patients were more likely to consume ABs and multi-step pathways. Reasons for choosing providers (e.g., cost, location, time) were conditioned by wider structural factors such as healthcare systems and AB availability.Conclusion There is likely to be a reinforcing cycle between complex, repetitive treatment pathways, AB consumption and ABR, which could become more common as ABR evolves. A focus on individual behaviours obscures the contextual challenges patients face when treatment seeking. Pluralistic healthcare landscapes may promote more complex treatment seeking and therefore inappropriate AB use. We recommend intervening on aspects of the treatment cycle amenable to change, focussing on medical facilities (e.g., accessible diagnostics, patient-doctor interactions, information flows), and community AB access points (e.g., drug sellers).
Background: Over-the-counter antibiotic access is common in low-and-middle-income countries, including Tanzania and Uganda, and this may accelerate antimicrobial resistance. Our study explores critical aspects of the drug seller-client interaction and antibiotic dispensing patterns for simulated COVID-19 symptoms during the pandemic in two study sites in countries with different government responses to the pandemic.Methods: Research assistants posing as clients approached different types of drug sellers such as pharmacies (Pharms), drug shops (DSs), and accredited drug dispensing outlets (ADDOs) in Mwanza, Tanzania (nPharms= 415, nADDOs= 116) and Mbarara, Uganda (nPharms= 440, nDSs= 67), from June 10-July 30, 2021. The mystery clients (who held no prescription) sought advice for simulated COVID-19 symptoms from the drug sellers, documented the quality of their interaction with sellers and the type of drugs dispensed.Results: Adherence to COVID-19 preventive measures and vigilance to COVID-19 symptoms was low in both sites but significantly higher in Uganda than in Tanzania. A higher percentage of drug sellers in Mbarara (Pharms= 36%, DSs= 35%, p-value= 0.947) compared to Mwanza (Pharms= 9%, ADDOs= 4%, p-value= 0.112) identified the client’s symptoms as possibly COVID-19. More than three-quarters of drug sellers in both Mbarara (Pharms= 86%, DSs= 89%) and Mwanza (Pharms= 93%, ADDOs= 97%) sold prescription-only medicines without asking for a prescription. A relatively high percentage of drug sellers that sold prescription-only medicines in Mwanza (Pharms= 51%, ADDOs= 67%) compared to Mbarara (Pharms= 31%, DSs= 42%) sold a partial course without any objection. Among the drug sellers who sold antibiotics, more drug sellers in Mbarara (Pharms= 73%, DSs= 78%, p-value= 0.580) compared to Mwanza (Pharms= 40% ADDOs= 46%, p-value= 0.537) sold antibiotics relevant for treating secondary bacterial infections in COVID-19 patients.Conclusion: Our study highlights low levels of awareness of and vigilance towards COVID-19 symptoms and widespread propensity to dispense prescription-only antibiotics without a prescription and to dispense partial doses of antibiotics. The implications of these for antimicrobial resistance are further discussed. Our study also highlights the need for more efforts to improve antibiotic stewardship among drug sellers in response to the current pandemic and to prepare them for future health emergencies.
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