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The Voice Disrupted: Articulation, Hesitation, and Moral Seriousness in F. R. Leavis's Pedagogy
Get PDFF. R. Leavis (1895–1978) stands as a central figure in twentieth-century English criticism and pedagogy. He became synonymous with ‘moral seriousness’ – the idea that literature demands ethical engagement from both critic and reader.1 For him, criticism was not a neutral exercise of taste but a committed act, one that required every word to bear the weight of conviction. By ‘moral seriousness’, I follow not the vague sense of ethical engagement sometimes ascribed to Leavis, but the Leavisian, meaning that Malcolm Pittock has more recently clarified: a criterion of authenticity in imaginative and critical response, close to Tolstoy's injunction that art should ‘make for life’.2 For Leavis, moral seriousness marked a quality of attention, the capacity to confront lived reality without evasion or spurious flourish. It is less a moralising attitude than a discipline of responsiveness. In this essay, I extend that sense into the corporeal register: Leavis's hesitations, pauses, and self-corrections embody this same seriousness, dramatising the struggle to speak truthfully from within the limits of language and the body
Uptake of community-based integrated HIV and sexual and reproductive health services for young people in Zimbabwe: the CHIEDZA study.
Get PDFINTRODUCTION: Limited engagement with health services contributes to the poorer HIV care outcomes observed in young people. We conducted a cluster-randomised trial to investigate the impact of community-based integrated HIV and sexual and reproductive health (SRH) service (CHIEDZA) for young people on HIV outcomes in three provinces in Zimbabwe. Here we examine the uptake of services. METHODS: In the 12 intervention arm clusters, weekly integrated HIV and SRH services were delivered from community centres to cluster residents aged 16-24 years over 30 months. Service components included HIV testing, treatment and adherence support, management of sexually transmitted infections (STIs), menstrual health management, provision of condoms and contraception, counselling, and a tailored package of educational text messages on SRH topics. All components were optional. Fingerprint scanning was used to register clients and track their attendances and service uptake over time. RESULTS: From April 2019-March 2022 36,991 clients attended CHIEDZA services, for a total of 78,810 visits; each centre had a median of 55 clients per day; 40.6% of clients returned for more than one visit. Overall, 75.0% of clients were female and 53.0% were aged 1 HIV test. At their first visit 78.6% of eligible clients had an HIV test, and out of those who were not tested at the first visit, 28.3% later returned and were tested. HIV incidence among those with HIV status recorded at more than 1 visit was 0.72 per 100 person years (95%CI 0.53-0.98). Overall, 377 clients tested HIV positive at CHIEDZA (prevalence 1.3%) of whom 70.3% linked to care either at CHIEDZA (n = 234) or with other service providers (n = 31). An additional 1162 clients were previously diagnosed with HIV. CONCLUSIONS: An integrated HIV and SRH programme had high attendance and service uptake, with most clients accessing multiple service components per visit, including HIV testing. Provision of integrated HIV and SRH services may increase service engagement and uptake by young people and facilitate programme efficiency. TRIAL REGISTRATION: The cluster-randomised trial was registered at www. CLINICALTRIALS: gov (Trial registration number: NCT03719521) on 17 October 2018 ( https://www. CLINICALTRIALS: gov/study/NCT03719521 )
Sociodemographic and clinical factors associated with non-adherence to stroke medication: an analytical, multi-hospital cross-sectional survey in Punjab, Pakistan.
Get PDFOBJECTIVE: Studying issues related to stroke medication non-adherence is essential for secondary prevention of stroke. This study aimed to identify the prevalence of medication non-adherence and risk factors among stroke survivors. The reasons behind this are that some patients may not follow stroke medication plans, and potential ways to help patients adhere better to medication plans. DESIGN: This study employed a cross-sectional patient survey. SETTING: The study was conducted in 20 public and private healthcare facilities in a resource-constrained setting, in Punjab, the largest province of Pakistan. PARTICIPANTS: We included 6538 stroke survivors aged 21-75 years with at least a 6 month history of stroke who were prescribed one or more anti-stroke medications and met the inclusion criteria. PRIMARY OUTCOME MEASURES: The main outcome was medication non-adherence, measured by the Self-Efficacy for Appropriate Medication Scale (SEAMS) and self-reported pill count. Descriptive statistics were used to summarise study variables. chi-square (χ²)/Fisher's exact test and independent t-test/ANOVA were employed. A generalised linear model (logit model using multivariable logistic regression shows that several factors are associated with medication non-adherence and adherence. Odds ratio (OR) plots were generated using Seaborn and Matplotlib. RESULTS: Non-adherence based on pill counts was 49.7%, while the mean SEAMS score (31.3±7.7) showed moderate self-reported adherence. After adjusting for age, gender, marital status, education, income, health insurance, smoking status, comorbidities, stroke type, disease duration, blood pressure control, number of medications, dosing frequency, physiotherapy continuation, perceived side effects and doctor-patient satisfaction, we found that female gender (vs male: AOR 0.31, 95% CI 0.27 to 0.35), lower income (10k-25k PKR vs >100k PKR: AOR 0.31, 95% CI 0.23 to 0.41; 26k-50k PKR vs >100k PKR: AOR 0.57, 95% CI 0.47 to 0.68), primary/secondary education (vs postgraduate: AOR 0.74, 95% CI 0.64 to 0.87), controlled BP (vs uncontrolled: AOR 0.66, 95% CI 0.59 to 0.73), longer disease duration (≥5 years vs <5 years: AOR 0.43, 95% CI 0.37 to 0.49), one time per day dosing (vs three times per day: AOR 0.25, 95% CI 0.21 to 0.29) and fewer medications (<5 vs 10+: AOR 0.50, 95% CI 0.43 to 0.58; 5-9 vs 10+: AOR 0.71, 95% CI 0.61 to 0.83) significantly reduced non-adherence odds (all p<0.001). Married status (vs other: AOR 1.22, 95% CI 1.02 to 1.45, p=0.028) and diabetes (vs obesity: AOR 1.29, 95% CI 1.09 to 1.53, p=0.003) increased non-adherence risk. CONCLUSION: This study addresses the significant issue of medication non-adherence in stroke patients in Pakistan, reflecting global patterns yet remaining under-explored locally. It emphasises the critical role of adherence in managing chronic conditions such as stroke, where consistent use of preventive therapies is vital for reducing recurrence and improving outcomes. While the non-adherence rates are consistent with global trends, there is a notable lack of observational studies and epidemiological data in the Pakistani context. Our findings support a comprehensive approach to enhance medication adherence, taking into account the complex connections among social, behavioural and clinical factors. It also highlights the importance of maintaining detailed records to monitor adherence trends, identify high-risk groups and inform targeted public health interventions
Developing a universal precautions approach to stigma reduction in health care: Insights from clinical and non-clinical health workers
Get PDFAmid calls for stigma reduction approaches that go beyond one condition, identity or practice and growing evidence of stigma as a common experience in the general population, we explored the possibility of a “universal precautions” approach. That is, that all people who attend for health care should be considered as worried about how they might be judged. To further develop this approach, semi-structured interviews were conducted with 30 health workers in clinical and non-clinical roles in Australia. Participants were generally supportive of a “universal” approach to stigma reduction (“there’s 1000 s of stigmas out there”) and wanted opportunity for all workers to participate in any programs. Participants were typically aware of the impact of stigma and drew on their own experience or that of family or friends to explain the long legacy of stigma for people’s interactions with health care systems. An element of misconception around stigma (what it looks like and why it can be damaging) was apparent in relation to practices that health workers engage in an effort to protect or care for their colleagues through communications that include irrelevant or judgemental information about patients. Health worker values of non-judgemental care and reflective practice were seen as important to draw upon to frame stigma reduction interventions which needed organisational support and leadership. Using quality standards and accreditation systems to drive further action on stigma reduction was also highlighted. These data will contribute to scoping potential approaches and limitations of a “universal precautions” approach to stigma reduction in health care
Co-occurring mental and substance use disorders in South African men: A Community survey
Get PDFBackground: The co-occurrence of mental and substance use disorders (SUDs) poses major public health challenges. Understanding their prevalence and risk factors is critical for developing targeted interventions.
Aim: To estimate the prevalence of substance use and risk of co-occurring common mental disorders in three South African provinces (Western Cape, Eastern Cape [EC] and North West [NW]).
Setting: The study was conducted in three provinces in South Africa (Madibeng district in NW province, King Sabata Dalindyebo [KSD] in the EC and Khayelitsha in the Western Cape).
Methods: A stratified multistage random household survey was conducted using the 9-item Patient Health Questionnaire (PHQ-9), 7-item Generalised Anxiety Disorder Assessment (GAD-7) and Primary Care PTSD Screen (PC-PTSD-5) to assess mental disorders. Alcohol and substance use were measured with the Alcohol Use Disorders Identification Test (AUDIT) and Drug Use Disorders Identification Test (DUDIT). Weighted prevalence estimates were calculated, and Rao–Scott adjusted Chi-square tests accounted for the complex survey design. Unweighted Chi-square tests explored demographic associations.
Results: Of 1597 participants, 64.9% screened positive for at least one mental disorder. The prevalence of alcohol use disorder (AUD) was 31.9% and SUD 7.4%. Co-occurrence of AUD and SUD was 6.3%. Alcohol use disorder was significantly associated with depression, anxiety and posttraumatic stress disorder (PTSD), whereas SUD (excluding alcohol) showed no significant associations.
Conclusion: Psychiatric comorbidity was partly associated with substance use. The findings highlight a substantial burden of co-occurring alcohol use and mental disorders among South African men, underscoring the need for integrated, trauma-informed primary healthcare services.
Contribution: The study provides population-based evidence to inform service delivery and policy for under-resourced settings
Tracking and appraising maternal and perinatal death surveillance and response implementation in Nigeria: a historical timeline and policy analysis.
Get PDFBACKGROUND: Nigeria bears one of the highest global burdens of maternal and perinatal mortality, despite decades of global and national efforts to address preventable deaths. Maternal and Perinatal Death Surveillance and Response (MPDSR) is a key strategy to reduce preventable deaths. This study synthesises the historical trajectory and policy evolution of MPDSR in Nigeria, examining factors shaping its uptake, scope, and institutionalisation. METHODS: We conducted a historical timeline and policy analysis using systematic review principles. Peer-reviewed and grey literature were retrieved through comprehensive database and web searches, complemented by stakeholder engagement. Data were extracted from 24 eligible documents and analysed using Walt and Gilson's policy triangle framework to explore policy content, context, actors, and processes over time. RESULTS: Four phases of MPDSR implementation were identified, showing a shift from facility-based maternal death reviews to broader inclusion of perinatal and community components. Federal policymakers and professional associations have driven national-level adoption, while state-level uptake varies depending on political will and capacity. Community and facility-based MPDSR have evolved as fragmented practices rather than an integrated system. Facility-level implementation is comparatively more established, while community-based MPDSR remain limited, donor-driven, and inconsistently integrated. Progress towards institutionalisation is hampered by weak legal frameworks and insufficient subnational capacity. Persistent challenges faced by frontline workers and variable community engagement further undermine MPDSR sustainability. CONCLUSION: To maximise the potential of MPDSR as a tool for accountability and system strengthening, Nigeria must integrate community and facility-based surveillance within a unified system, backed by legislation, sustained financing, and capacity building
Ending nuclear weapons, before they end us
Get PDFn May 2025, the World Health Assembly (WHA) will vote on
re- establishing a mandate for the World Health Organization
(WHO) to address the health consequences of nuclear weapons
and war.1 Health professionals and their associations should
urge their governments to support such a mandate and support
the new United Nations (UN) comprehensive study on the
effects of nuclear wa
Experiences of Australian adults with disabilities living with government supports in the home during the COVID-19 pandemic
Get PDFAdults with disabilities who live with government supports in their homes were among those most heavily impacted by COVID-19 public health measures, though few studies have considered the lived experiences of this group. This study invited Australian adults with disabilities who lived with government supports under the National Disability Insurance Scheme during the pandemic to share their experiences. The focus was changes in life satisfaction before, during and since stay-at-home orders (i.e. ‘lockdowns’). Thirty-four Australian adults completed an online survey. Findings revealed a decline in life satisfaction and mental health during lockdowns by comparison with pre-pandemic times. Informal supporters and paid support services were important but difficult to access during this period. Communication and community awareness of the challenges associated with public health policy for people with disabilities and their supporters were key issues. Resources addressing future health crises should be co-designed with people with disabilities and their supporters
Association of environmental enteropathy with prediabetes and diabetes: A cross-sectional study among Tanzanian adults.
Get PDFOBJECTIVES: Environmental enteropathy (EE) may increase the risk of diabetes, but data are limited. We assessed the role of EE on markers of glucose metabolism.
METHODS: Cross-sectional study among Tanzanian adults assessing EE and diabetes was conducted between 2019 and 2021. Data on demography, body mass index (BMI), Human immunodeficiency virus (HIV), EE (i.e., fecal myeloperoxidase, lipopolysaccharide binding protein, and markers of intestinal permeability and absorption capacity), glucose and insulin were collected. Data reduction using principal components analysis produced two components: sugar uptake and inflammatory EE. Tertiles were used to define EE severity as: lower, middle, and upper. The main outcome, combined prediabetes and diabetes, was defined as 2-hour oral glucose tolerance test (OGTT) glucose ≥7.8 mmol/L. Lower homeostatic model assessment (HOMA)-β and insulinogenic index, higher HOMA-insulin resistance (HOMA-IR), and lower Matsuda index were secondary outcomes. Logistic regression assessed the associations and HIV and BMI groups were tested as effect modifiers.
RESULTS: A total of 612 participants were included. The mean (±SD) age was 42.0 (±11.6) years and 57.2% (350) were females. Eighty (13%) were underweight, 367 (60%) normal weight, 165 (27%) overweight, and 357 (58%) were HIV-infected. We found no overall association of EE on the main outcome, but BMI and HIV modified the associations. Compared to lower tertile of sugar uptake EE, the upper tertile was associated with marginally significant higher odds of prediabetes and diabetes (OR=2.1 (95% CI: 0.9, 4.9; P = 0.06)) and marginally significant higher HOMA-IR (OR=2.6 (1.0, 6.8; P = 0.06)) among overweight and obese participants. Similarly, compared to the lower tertile, the upper tertile of inflammatory EE was associated with higher odds of prediabetes and diabetes (OR=2.1 (1.1, 4.1; P = 0.03)) among HIV-uninfected participants, whereas among HIV-infected participants those in the middle tertile compared to those in the lower tertile had higher odds of lower Matsuda index (OR=2.3 (1.1, 4.7; P = 0.03)).
CONCLUSIONS: EE may increase the risk of prediabetes and diabetes among those who are overweight and in individuals who are not HIV-infected. Longitudinal studies on the role of EE on diabetes are needed to confirm these results to provide the basis for developing and testing novel interventions to combat diabetes in Africa
Effect of mass campaigns with full and fractional doses of pneumococcal conjugate vaccine (Pneumosil) on the reduction of nasopharyngeal pneumococcal carriage in Niger: a three-arm, open-label, cluster-randomised trial.
Get PDFBACKGROUND: In settings with low pneumococcal conjugate vaccine (PCV) coverage, multi-age cohort mass campaigns could increase population immunity, and fractional dosing could increase affordability. We aimed to evaluate the effect of mass campaigns on nasopharyngeal pneumococcal carriage of Pneumosil (PCV10) in children aged 1-9 years in Niger. METHODS: In this three-arm, open-label, cluster-randomised trial, 63 clusters of one to four villages in Niger were randomly assigned (3:3:1) using block randomisation to receive campaigns consisting of a single full dose of a 10-valent PCV (Pneumosil), a single one-fifth dose of Pneumosil, or no campaign. Independently sampled carriage surveys were done among 2268 households 6 months before and after vaccination, collecting nasopharyngeal swabs from healthy children for culture and serotyping; those with contraindication to nasopharyngeal swabbing were excluded. The primary outcome was nasopharyngeal carriage of vaccine-serotype pneumococcus. We tested whether vaccine-type carriage was reduced in full-dose versus control clusters; and whether fractional doses were non-inferior to full-doses (lower bound 95% CI more than -7·5%), using generalised estimating equations to analyse cluster summaries at baseline and follow-up, controlling for covariates to estimate risk differences and their 95% CIs. The study is registered with ClinicalTrials.gov (NCT05175014) and the Pan-African Clinical Trials Registry (PACTR20211257448484). FINDINGS: Surveys were done between Dec 22, 2021, and March 18, 2022, and between Dec 12, 2022, and March 9, 2023. The vaccination campaign ran from June 15 to Aug 2, 2022. Participants' characteristics were consistent across surveys and groups. Pre-vaccination, vaccine-type carriage was 15·6% (149 of 955 participants) in the full-dose group, 17·9% (170 of 948) in the fractional-dose group, and 18·8% (60 of 320) in the control group. Post-vaccination, vaccine-type carriage was 4·6% (44 of 967) in the full-dose group, 8·0% (77 of 962) in the fractional-dose group, and 16·5% (53 of 321) in the control group. The primary analysis showed a risk difference of -16·2% (95% CI -28·6 to -3·0) between the full-dose group and control group (p=0·002 for superiority), and -3·8% (-6·1 to -1·6) between the full-dose group and fractional-dose group, meeting the non-inferiority criteria. No adverse events were judged to be related to vaccination. INTERPRETATION: Multi-age cohort campaigns had a marked effect on vaccine-type carriage and fractional-dose campaigns met non-inferiority criteria. Such campaigns should be considered in low-coverage settings, including humanitarian emergencies, to accelerate population protection. FUNDING: EDCTP2 programme supported by the EU. TRANSLATION: For the French translation of the abstract see Supplementary Materials section