Considerations for developing and implementing a safe list for alien taxa.

Many species have been intentionally introduced to new regions for their benefits. Some of these alien species cause damage, others do not (or at least have not yet). There are several approaches to address this problem: prohibit taxa that will cause damage, try to limit damages while preserving benefits, or promote taxa that are safe. In the present article, we unpack the safe list approach, which we define as "a list of taxa alien to the region of interest that are considered of sufficiently low risk of invasion and impact that the taxa can be widely used without concerns of negative impacts." We discuss the potential use of safe lists in the management of biological invasions; disentangle aspects related to the purpose, development, implementation, and impact of safe lists; and provide guidance for those considering to develop and implement such lists.

Challenging the food waste hierarchy.

Food waste is a multi-faceted and complex problem for urban circular economies with far-reaching environmental impacts. Effectively addressing this problem requires a comprehensive understanding of the food waste impacts on food, energy, water, and climate (FEWC) systems. Despite complex dynamics in the FEWC nexus, the most popular guidance for food waste management is the food waste hierarchy framework - which fails to account for ensuing impacts on all nexus elements. Aiming to optimise the framework, we adopt a participatory approach to develop the first comprehensive and replicable system dynamics model of the FEWC footprints of urban food waste throughout the agri-food supply chain. The quantitative model compares different food waste management options, and relevant policies in Bristol, UK (2018-2030). Unlike the guidance of the traditional waste hierarchy framework, our findings show that the preferability of each option can vary for each sector within the supply chain and for each FEWC element. Our results show that increasing food surplus redistribution in the supply sectors and reducing food waste in consumer sectors are the most preferable approaches to reduce the environmental impacts of food. Feeding food leftover to pets at household level also has a promising impact. Other options involve trade-offs between energy and carbon footprints, while having minimal impact on water footprint. We conclude that the traditional food waste hierarchy is too simplified to provide reliable guidance for environmentally sustainable food waste management and policy. Instead, we present an improved food waste hierarchy framework that accounts for the scale of preferability of each option for different sectors and different FEWC nexus elements. This novel framework thus provides more nuanced and more robust understanding of food waste impacts on the FEWC nexus in urban circular economies, thereby enabling the development of policy and management options that are optimised for environmental sustainability.

Stakeholder engagement in the study and management of invasive alien species.

Invasive alien species are a major driver of global environmental change and a range of management interventions are needed to manage their effects on biodiversity, ecosystem services, human well-being and local livelihoods. Stakeholder engagement is widely advocated to integrate diverse knowledge and perspectives in the management of invasive species and to deal with potential conflicts of interest. We reviewed the literature in the ISI Web of Science on stakeholder engagement (the process of involving stakeholders (actors) in decision making, management actions and knowledge creation) in invasion science to assess and understand what has been done (looking at approaches and methodologies used, stakeholders involved, and outcomes from engagement) and to make recommendations for future work. Research on stakeholder engagement in invasion science has increased over the last decade, helping to improve scientific knowledge and contributing towards policy formulation and co-implementation of management. However, many challenges remain and engagement could be made more effective. For example, most studies engage only one stakeholder group passively using questionnaires, primarily for assessing local knowledge and perceptions. Although useful for management and policy planning, these stakeholders are not active participants and there is no two-way flow of knowledge. To make stakeholder involvement more useful, we encourage more integrative and collaborative engagement to (1) improve co-design, co-creation and co-implementation of research and management actions; (2) promote social learning and provide feedback to stakeholders; (3) enhance collaboration and partnerships beyond the natural sciences and academia (interdisciplinary and transdisciplinary collaboration); and (4) discuss some practical and policy suggestions for improving stakeholder engagement in invasion science research and management. This will help facilitate different stakeholders to work better together, allowing problems associated with biological invasions to be tackled more holistically and successfully.

A framework for engaging stakeholders on the management of alien species.

Alien species can have major ecological and socioeconomic impacts in their novel ranges and so effective management actions are needed. However, management can be contentious and create conflicts, especially when stakeholders who benefit from alien species are different from those who incur costs. Such conflicts of interests mean that management strategies can often not be implemented. There is, therefore, increasing interest in engaging stakeholders affected by alien species or by their management. Through a facilitated workshop and consultation process including academics and managers working on a variety of organisms and in different areas (urban and rural) and ecosystems (terrestrial and aquatic), we developed a framework for engaging stakeholders in the management of alien species. The proposed framework for stakeholder engagement consists of 12 steps: (1) identify stakeholders; (2) select key stakeholders for engagement; (3) explore key stakeholders' perceptions and develop initial aims for management; (4) engage key stakeholders in the development of a draft management strategy; (5) re-explore key stakeholders' perceptions and revise the aims of the strategy; (6) co-design general aims, management objectives and time frames with key stakeholders; (7) co-design a management strategy; (8) facilitate stakeholders' ownership of the strategy and adapt as required; and (9) implement the strategy and monitor management actions to evaluate the need for additional or future actions. In case additional management is needed after these actions take place, some extra steps should be taken: (10) identify any new stakeholders, benefits, and costs; (11) monitor engagement; and (12) revise management strategy. Overall, we believe that our framework provides an effective approach to minimize the impact of conflicts created by alien species management.

Does treatment collection and observation each day keep the patient away? An analysis of the determinants of adherence among patients with Tuberculosis in South Africa.

Directly observed treatment short course (DOTS) has been the recommended strategy for Tuberculosis (TB) control since 1995. Developed as an alternative to inpatient treatment, it involves observation of patients' medication intake to promote adherence. However, the burden of daily clinic visits may affect access to care. Using a mixed methods approach, we consider whether (1) non-adherence differs systematically between patients required to make daily clinic visits and patients cared for under less frequent clinic visits and (2) the association between frequency of required clinic visits and adherence depends on affordability and acceptability of care. Data were collected in facility exit interviews with 1200 TB patients in two rural and two urban sub-districts in South Africa. Additionally, 17 in-depth interviews were completed with TB patients. After controlling for socioeconomic and demographic factors, patient type (new or retreatment) and treatment duration, regression analyses showed that daily attending patients were over twice as likely to report a missed clinic visit (P < 0.001) or a missed dose of treatment (P = 0.002) compared with patients required to attend clinics for treatment collection less frequently. Missed visits increased with treatment duration (P = 0.01). The significant interaction between clinic visit frequency and treatment duration indicated that sustaining daily visits over time may become increasingly difficult over the course of treatment. The qualitative analysis identified treatment cost and duration, patients' physical condition and varying social contexts (family, community and work) as important influences on adherence. These findings suggest that strategies involving daily clinic visits may require reconsideration if resources for TB care are to be used efficiently. The adoption of approaches that place patient interests at the centre of TB treatment delivery would appear to be of high priority, particularly in countries where TB prevalence is high and resources for TB care are highly constrained.

Endurance, resistance and resilience in the South African health care system: case studies to demonstrate mechanisms of coping within a constrained system.

BACKGROUND: South Africa is at present undertaking a series of reforms to transform public health services to make them more effective and responsive to patient and provider needs. A key focus of these reforms is primary care and its overburdened, somewhat dysfunctional and hierarchical nature. This comparative case study examines how patients and providers respond in this system and cope with its systemic demands through mechanisms of endurance, resistance and resilience, using coping and agency literatures as the theoretical lenses. METHODS: As part of a larger research project carried out between 2009 and 2010, this study conducted semi-structured interviews and observations at health facilities in three South African provinces. This study explored patient experiences of access to health care, in particular, ways of coping and how health care providers cope with the health care system's realities. From this interpretive base, four cases (two patients, two providers) were selected as they best informed on endurance, resistance and resilience. Some commentary from other respondents is added to underline the more ubiquitous nature of these coping mechanisms. RESULTS: The cases of four individuals highlight the complexity of different forms of endurance and passivity, emotion- and problem-based coping with health care interactions in an overburdened, under-resourced and, in some instances, poorly managed system. Patients' narratives show the micro-practices they use to cope with their treatment, by not recognizing victimhood and sometimes practising unhealthy behaviours. Providers indicate how they cope in their work situations by using peer support and becoming knowledgeable in providing good service. CONCLUSIONS: Resistance and resilience narratives show the adaptive power of individuals in dealing with difficult illness, circumstances or treatment settings. They permit individuals to do more than endure (itself a coping mechanism) their circumstances, though resistance and resilience may be limited. These are individual responses to systemic forces. To transform health care, mutually supportive interactions are required among and between both patients and providers but their nature, as micro-practices, may show a way forward for system change.

Disability Grant: a precarious lifeline for HIV/AIDS patients in South Africa.

BACKGROUND: In South Africa, HIV/AIDS remains a major public health problem. In a context of chronic unemployment and deepening poverty, social assistance through a Disability Grant (DG) is extended to adults with HIV/AIDS who are unable to work because of a mental or physical disability. Using a mixed methods approach, we consider 1) inequalities in access to the DG for patients on ART and 2) implications of DG access for on-going access to healthcare. METHODS: Data were collected in exit interviews with 1200 ART patients in two rural and two urban health sub-districts in four different South African provinces. Additionally, 17 and 18 in-depth interviews were completed with patients on ART treatment and ART providers, respectively, in three of the four sites included in the quantitative phase. RESULTS: Grant recipients were comparatively worse off than non-recipients in terms of employment (9.1 % vs. 29.9 %) and wealth (58.3 % in the poorest half vs. 45.8 %). After controlling for socioeconomic and demographic factors, site, treatment duration, adherence and concomitant TB treatment, the regression analyses showed that the employed were significantly less likely to receive the DG than the unemployed (p < 0.001). Also, patients who were longer on treatment and receiving concomitant treatment (i.e., ART and tuberculosis care) were more likely to receive the DG (significant at the 5 % level). The qualitative analyses indicated that the DG alleviated the burden of healthcare related costs for ART patients. Both patients and healthcare providers spoke of the complexity of the grants process and eligibility criteria as a barrier to accessing the grant. This impacted adversely on patient-provider relationships. CONCLUSIONS: These findings highlight the appropriateness of the DG for people living with HIV/AIDS. However, improved collaboration between the Departments of Social Development and Health is essential for preparing healthcare providers who are at the interface between social security and potential recipients.

Acceptable care? Illness constructions, healthworlds, and accessible chronic treatment in South Africa.

Achieving equitable access to health care is an important policy goal, with access influenced by affordability, availability, and acceptability of specific services. We explore patient narratives from a 5-year program of research on health care access to examine relationships between social constructions of illness and the acceptability of health services in the context of tuberculosis treatment and antiretroviral therapy in South Africa. Acceptability of services seems particularly important to the meanings patients attach to illness and care, whereas-conversely-these constructions appear to influence what constitutes acceptability and hence affect access to care. We highlight the underestimated role of individually, socially, and politically constructed healthworlds; traditional and biomedical beliefs; and social support networks. Suggested policy implications for improving acceptability and hence overall health care access include abandoning patronizing approaches to care and refocusing from treating "disease" to responding to "illness" by acknowledging and incorporating patients' healthworlds in patient-provider interactions.

Hopes interrupted: accessing and experiences of antiretroviral therapy in South Africa.

OBJECTIVES: Using the example of South Africa, this study aimed to examine and obtain a better understanding of the experiences and challenges of urban and rural patients on antiretroviral therapy (ART) in accessing this complex treatment in a resource-limited setting. METHODS: Following a narrative approach, in-depth interviews were conducted with 20 patients successfully and unsuccessfully (ie, with interruptions) receiving ART in urban Johannesburg and rural Bushbuckridge, using a detailed interview guide structured to illuminate interviewees' life circumstances and contextualise illness and treatment trajectories. Participants were interviewed by trained fieldworkers in their local languages. The translated and transcribed interviews were coded by several team members. Codes were cross-examined and showed good congruence. RESULTS: All interviewees emphasised the positive aspects of receiving ART, the lifeline and hope it provided by improving health, increasing their ability to live actively and reducing visible signs of (stigmatised) illness. Important factors supporting continuing adherence included social and economic support by individuals, role models and networks as well as positive experiences within the healthcare system and of the treatment itself. The main challenges were linked to patients' difficult life circumstances, especially those related to poverty (eg, transport and food costs) and health system constraints, including perceived lack of compassion and flexibility by healthcare workers. CONCLUSIONS: While there are many challenges for the sustainability of ART on an individual and health system level, this study emphasised the need for a patient-centric focus to continue to provide and increase the number of HIV-positive people receiving this lifeline, receiving hope.