RESUMEN
BACKGROUND: HIV drug resistance (HIVDR) continues to threaten the effectiveness of worldwide antiretroviral therapy (ART). Emergence and transmission of HIVDR are driven by several interconnected factors. Though much has been done to uncover factors influencing HIVDR, overall interconnectedness between these factors remains unclear and African policy makers encounter difficulties setting priorities combating HIVDR. By viewing HIVDR as a complex adaptive system, through the eyes of multi-disciplinary HIVDR experts, we aimed to make a first attempt to linking different influencing factors and gaining a deeper understanding of the complexity of the system. METHODS: We designed a detailed systems map of factors influencing HIVDR based on semi-structured interviews with 15 international HIVDR experts from or with experience in sub-Saharan Africa, from different disciplinary backgrounds and affiliated with different types of institutions. The resulting detailed system map was conceptualized into three main HIVDR feedback loops and further strengthened with literature evidence. RESULTS: Factors influencing HIVDR in sub-Saharan Africa and their interactions were sorted in five categories: biology, individual, social context, healthcare system and 'overarching'. We identified three causal loops cross-cutting these layers, which relate to three interconnected subsystems of mechanisms influencing HIVDR. The 'adherence motivation' subsystem concerns the interplay of factors influencing people living with HIV to alternate between adherence and non-adherence. The 'healthcare burden' subsystem is a reinforcing loop leading to an increase in HIVDR at local population level. The 'ART overreliance' subsystem is a balancing feedback loop leading to complacency among program managers when there is overreliance on ART with a perceived low risk to drug resistance. The three subsystems are interconnected at different levels. CONCLUSIONS: Interconnectedness of the three subsystems underlines the need to act on the entire system of factors surrounding HIVDR in sub-Saharan Africa in order to target interventions and to prevent unwanted effects on other parts of the system. The three theories that emerged while studying HIVDR as a complex adaptive system form a starting point for further qualitative and quantitative investigation.
Asunto(s)
Fármacos Anti-VIH , Infecciones por VIH , Personal Administrativo , África del Sur del Sahara , Fármacos Anti-VIH/uso terapéutico , Resistencia a Medicamentos , Farmacorresistencia Viral , Infecciones por VIH/epidemiología , HumanosRESUMEN
HIV drug resistance (HIVDR) is a complex problem with multiple interconnected and context dependent causes. Although the factors influencing HIVDR are known and well-studied, HIVDR remains a threat to the effectiveness of antiretroviral therapy. To understand the complexity of HIVDR, a comprehensive, systems approach is needed. Therefore, a local systems map was developed integrating all reported factors influencing HIVDR in the Dar es Salaam Urban Cohort Study area in Tanzania. The map was designed based on semi-structured interviews and workshops with people living with HIV and local actors who encounter people living with HIV during their daily activities. We visualized the feedback loops driving HIVDR, compared the local map with a systems map for Sub-Saharan Africa, previously constructed from interviews with international HIVDR experts, and suggest potential interventions to prevent HIVDR. We found several interconnected balancing and reinforcing feedback loops related to poverty, stigmatization, status disclosure, self-esteem, knowledge about HIVDR and healthcare system workload, among others, and identified three potential leverage points. Insights from this local systems map were complementary to the insights from the Sub-Saharan systems map showing that both viewpoints are needed to fully understand the system. This study provides a strong baseline for quantitative modelling, and for the identification of context-dependent, complexity-informed leverage points.
RESUMEN
This paper presents an overview of the theoretical background concerning the challenges for secondary school teachers implementing cooperative learning in areas such as alternative student assessment technique, student's resistance to collaborative techniques, planning and class management, teacher training, advancement, and evaluation. The research is based upon data gathered in the Italian Veneto and Emilia Romagna regions through focus groups with secondary school teachers. The educational project focuses on the use of critical incidents as training and educational tools with particular attention for cooperative learning approaches to transition situations and intercultural learning. It reviews different methodological options and explores ways to apply the critical incidents method in addressing the screening and development of intercultural competence within cooperative learning educational settings
Este artículo presenta una visión general de las bases teóricas acerca de los retos que supone para los profesores de Educación Secundaria la implementación del aprendizaje cooperativo, en campos como las técnicas alternativas de evaluación del aprendizaje, la oposición de los estudiantes a las técnicas de colaboración, la planificación y gestión del aula, la formación del profesorado, la promoción y la evaluación. La investigación se basa en los datos recopilados en las regiones italianas de Véneto y Emilia Romagna a través de grupos de discusión con profesores de enseñanza secundaria. El proyecto educativo se centra en el uso de los incidentes críticos como la formación y las herramientas educativas, prestando especial atención a los enfoques de aprendizaje cooperativo en las situaciones de transición y en el aprendizaje intercultural. Se examinan diferentes opciones metodológicas y se analizan formas de aplicar el método de incidentes críticos para abordar la detección y el desarrollo de la competencia intercultural en entornos educativos de aprendizaje cooperativo