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Abstract

Background

Diagnosing tuberculosis (TB) in children presents considerable challenges. Upfront testing on Xpert® MTB/RIF (‘Xpert’)—a rapid molecular assay with high sensitivity and specificity—for pediatric presumptive TB patients, as recommended by India’s Revised National Tuberculosis Control Program (RNTCP), can pave the way for early TB diagnosis. As part of an ongoing project implemented by Foundation for Innovative New Diagnostics (FIND) dedicated to providing upfront free-of-cost (FOC) Xpert testing to children seeking care in the public and private sectors, a qualitative assessment was designed to understand how national guidelines on TB diagnosis and Xpert technology have been integrated into the pediatric TB care practices of different health providers.

Methods

We conducted semi-structured interviews with a sample of health providers from public and private sectors engaged in the ongoing pediatric project in 4 major cities of India. Providers were sampled from intervention data based on sector of practice, number of Xpert referrals, and TB detection rates amongst referrals. A total of 55 providers were interviewed with different levels of FOC Xpert testing uptake. Data were transcribed and analyzed inductively by a medical anthropologist using thematic content analysis and narrative analysis.

Results

It was observed that despite guidance from RNTCP on the use of Xpert and significant efforts by FIND and state authorities to disseminate these guidelines, there was notable diversity in their implementation by different health care providers. Xpert, apart from being utilized as intended, i.e. as a first diagnostic test for children, was utilized variably–as an initial screening test (to rule out TB), confirmatory test (once TB diagnosis is established based on antibiotic trial or clinically) and/or only for drug susceptibility testing after TB diagnosis was confirmed. Most providers who used Xpert frequently reported that Xpert was an important tool for managing pediatric TB cases, by reducing the proportion of cases diagnosed only on clinical suspicion and by providing upfront information on drug resistance, which is seldom suspected in children. Despite non-standard use, these results showed that Xpert access helped raise awareness, aided in antibiotic stewardship, and reduced dependence on clinical diagnosis among those who diagnose and treat TB in children.

Conclusion

Access to free and rapid Xpert testing for all presumptive pediatric TB patients has had multiple positive effects on pediatricians’ diagnosis and treatment of TB. It has important effects on speed of diagnosis, empirical treatment, and awareness of drug resistance among TB treatment naive children. In addition, our study shows that access to public sector Xpert machines may be an important way to encourage Public-Private integration and facilitate the movement of patients from the private to public sector for anti-TB treatment. Despite availability of rapid and free Xpert testing, our study showed an alarming diversity of Xpert utilization strategies across different providers who may be moving toward suggested practice over time. The degree of diversity in TB diagnostic approaches in children reported here highlights the urgent need for concerted efforts to place Xpert early in diagnostic algorithms to positively impact the pediatric TB care pathway. A positive change in diagnostic algorithms may be possible with continued advocacy, time, and increased access.

Abstract

This article reexamines medical anthropology theories of symptom, illness, and disease to consider unregulated medical care in India. It builds on clinical observations, an inventory of the pharmaceuticals used by men who call themselves “Bengali doctors,” and their patients to understand medical care in a context that privileges symptom not disease. It draws on Derrida's use of pharmakon to outline the complexities of care and embodiment and helps locate local and medical anthropology theories of symptom and pharmaceuticals within theories of the experiential body. It asks two key questions: What is medical care without disease and what are its implications on a local biology in which disease‐based biomedicine is modified? Searching for a tentative answer, it works to bring medical anthropology's interest in symptom back to the body without losing symptoms’ connection to political economies, individual experience, and localized biomedicine. [post_title] => Mohit's Pharmakon: Symptom, Rotational Bodies, and Pharmaceuticals in Rural Rajasthan [post_excerpt] => [post_status] => publish [comment_status] => closed [ping_status] => closed [post_password] => [post_name] => mohits-pharmakon-symptom-rotational-bodies-and-pharmaceuticals-in-rural-rajasthan [to_ping] => [pinged] => [post_modified] => 2021-04-06 12:43:38 [post_modified_gmt] => 2021-04-06 16:43:38 [post_content_filtered] => [post_parent] => 0 [guid] => https://sshiftb.org/?post_type=resources&p=1474 [menu_order] => 0 [post_type] => resources [post_mime_type] => [comment_count] => 0 [filter] => raw ) [2] => WP_Post Object ( [ID] => 1473 [post_author] => 4 [post_date] => 2021-04-06 12:29:38 [post_date_gmt] => 2021-04-06 16:29:38 [post_content] =>

Abstract

Triage is a process of categorizing potential health and guiding care. It is based on the idea that all bodies are equal while potential vitality is not. I examine the triage processes used by Indian physicians as they collaborated with global health researchers to identify patients for a free, cutting-edge tuberculosis test. As I argue, triage forms and reforms social difference within global health despite its aspirations of standardization and experimentality. Problematizing triage as part of global health’s ordinary affect of affordability reveals local biologies, class biopolitics, and clinical speculation in the field. I conclude by considering new avenues of ethnographic inquiry that are opened by attending to the practiced and depoliticized biopolitics that occurs within clinics as everyday, nonreflexive decisions about how to organize resources and speculate on vitalities. [post_title] => Dr. Ram’s triage: Categorization, speculation, and granting access to global health technologies in Indian private clinics [post_excerpt] => [post_status] => publish [comment_status] => closed [ping_status] => closed [post_password] => [post_name] => dr-rams-triage-categorization-speculation-and-granting-access-to-global-health-technologies-in-indian-private-clinics [to_ping] => [pinged] => [post_modified] => 2021-04-06 12:29:38 [post_modified_gmt] => 2021-04-06 16:29:38 [post_content_filtered] => [post_parent] => 0 [guid] => https://sshiftb.org/?post_type=resources&p=1473 [menu_order] => 0 [post_type] => resources [post_mime_type] => [comment_count] => 0 [filter] => raw ) [3] => WP_Post Object ( [ID] => 1472 [post_author] => 4 [post_date] => 2021-04-06 12:26:09 [post_date_gmt] => 2021-04-06 16:26:09 [post_content] =>

Abstract

Public health experts often describe care in India’s private sector as ‘chaotic,’ ‘substandard,’ ‘profit-driven,’ and ‘arbitrary.’ Discourse tends to focus on the ‘predatory behavior' of doctors who demand consultation fees and kickbacks for everything from medicine, to laboratory tests, to specialist referrals, and even hospital stays. These practices are ethnographically observable. However, this discourse does not take into account the multiple uncertainties, ethical complexity, and personal relationships involved in providing care in exchange for money in a setting of scarce personal and public resources. Situated at the very end of a value chain designed to make money from health, or the lack thereof, private physicians find themselves embroiled in moral peril. In this article, I engage what it means to make a livelihood in a context such as this by considering the economic, moral, and epistemic practices that physicians and their patients use to create and evaluate the value of pharmaceuticals in Mumbai’s slums. Based on over a year of clinic ethnography and interviews with family physicians, specialists, pharmacists, and pharmaceutical wholesalers, I trace how physicians manage the effects of a pharmaceutical value chain that produces profit by fulfilling patient’s health needs and desires. [post_title] => Dr. Zahir’s dilemma: money and morals in India’s private medical networks [post_excerpt] => [post_status] => publish [comment_status] => closed [ping_status] => closed [post_password] => [post_name] => dr-zahirs-dilemma-money-and-morals-in-indias-private-medical-networks [to_ping] => [pinged] => [post_modified] => 2021-04-06 12:26:10 [post_modified_gmt] => 2021-04-06 16:26:10 [post_content_filtered] => [post_parent] => 0 [guid] => https://sshiftb.org/?post_type=resources&p=1472 [menu_order] => 0 [post_type] => resources [post_mime_type] => [comment_count] => 0 [filter] => raw ) [4] => WP_Post Object ( [ID] => 1469 [post_author] => 4 [post_date] => 2021-04-06 11:55:43 [post_date_gmt] => 2021-04-06 15:55:43 [post_content] =>

About the book

Neoliberalism has been the defining paradigm in global health since the latter part of the twentieth century. What started as an untested and unproven theory that the creation of unfettered markets would give rise to political democracy led to policies that promoted the belief that private markets were the optimal agents for the distribution of social goods, including health care. A vivid illustration of the infiltration of neoliberal ideology into the design and implementation of development programs, this case study, set in post-Soviet Tajikistan’s remote eastern province of Badakhshan, draws on extensive ethnographic and historical material to examine a “revolving drug fund” program—used by numerous nongovernmental organizations globally to address shortages of high-quality pharmaceuticals in poor communities. Provocative, rigorous, and accessible, Blind Spot offers a cautionary tale about the forces driving decision making in health and development policy today, illustrating how the privatization of health care can have catastrophic outcomes for some of the world’s most vulnerable populations. [post_title] => Blind Spot How Neoliberalism Infiltrated Global Health [post_excerpt] => [post_status] => publish [comment_status] => closed [ping_status] => closed [post_password] => [post_name] => blind-spot-how-neoliberalism-infiltrated-global-health [to_ping] => [pinged] => [post_modified] => 2021-04-06 11:55:44 [post_modified_gmt] => 2021-04-06 15:55:44 [post_content_filtered] => [post_parent] => 0 [guid] => https://sshiftb.org/?post_type=resources&p=1469 [menu_order] => 0 [post_type] => resources [post_mime_type] => [comment_count] => 0 [filter] => raw ) [5] => WP_Post Object ( [ID] => 1468 [post_author] => 4 [post_date] => 2021-04-06 11:48:26 [post_date_gmt] => 2021-04-06 15:48:26 [post_content] =>

Abstract

Objectives This study explored the acceptability of cough etiquette, wearing masks and separation by tuberculosis (TB) suspects and TB patients in two districts in Uganda. Design The study was conducted in Mukono and Wakiso districts in central Uganda. Eighteen in-depth interviews with patients and eight focus group discussions with health workers were conducted. Patients were asked for their opinions on cough etiquette, patient separation and wearing of masks. Results Patients and health workers felt that physical separation was ideal, yet separation and masking were regarded as embarrassing to patients, emphasizing their potential infectiousness. Patients reported greater willingness to cover their mouth with a handkerchief than to wear a mask. Good counseling and health education were suggested to improve patients’ adoption of separation and masking. However patients expressed concerns about equity, coercive and stigmatizing approaches. Universal precautions were more acceptable than targeted ones, with the exception of separating TB patients. Lack of community awareness about airborne transmission of TB was identified as a barrier to accepting and adopting TB infection control measures. Conclusion Scaling up effective TB infection control norms and behaviors requires a patient-centered, rights-based, and evidence-based approach. Socially acceptable measures like covering the mouth and nose with a handkerchief should be promoted. We recommend that further studies are needed to explore how community advocacy impacts on acceptability of masking. Furthermore, the efficacy of covering the mouth using a handkerchief or piece of cloth compared to wearing a mask in TB prevention needs to be evaluated. [post_title] => Acceptability of masking and patient separation to control nosocomial Tuberculosis in Uganda: A qualitative study [post_excerpt] => [post_status] => publish [comment_status] => closed [ping_status] => closed [post_password] => [post_name] => acceptability-of-masking-and-patient-separation-to-control-nosocomial-tuberculosis-in-uganda-a-qualitative-study [to_ping] => [pinged] => [post_modified] => 2021-04-06 11:48:26 [post_modified_gmt] => 2021-04-06 15:48:26 [post_content_filtered] => [post_parent] => 0 [guid] => https://sshiftb.org/?post_type=resources&p=1468 [menu_order] => 0 [post_type] => resources [post_mime_type] => [comment_count] => 0 [filter] => raw ) [6] => WP_Post Object ( [ID] => 1467 [post_author] => 4 [post_date] => 2021-04-06 11:45:01 [post_date_gmt] => 2021-04-06 15:45:01 [post_content] =>

Abstract

Background

Stigma is associated with health conditions that drive disease burden in low- and middle-income countries (LMICs), including HIV, tuberculosis, mental health problems, epilepsy, and substance use disorders. However, the literature discussing the relationship between stigma and health outcomes is largely fragmented within disease-specific siloes, thus limiting the identification of common moderators or mechanisms through which stigma potentiates adverse health outcomes as well as the development of broadly relevant stigma mitigation interventions.

Methods

We conducted a scoping review to provide a critical overview of the breadth of research on stigma for each of the five aforementioned conditions in LMICs, including their methodological strengths and limitations.

Results

Across the range of diseases and disorders studied, stigma is associated with poor health outcomes, including help- and treatment-seeking behaviors. Common methodological limitations include a lack of prospective studies, non-representative samples resulting in limited generalizability, and a dearth of data on mediators and moderators of the relationship between stigma and health outcomes.

Conclusions

Implementing effective stigma mitigation interventions at scale necessitates transdisciplinary longitudinal studies that examine how stigma potentiates the risk for adverse outcomes for high-burden health conditions in community-based samples in LMICs. [post_title] => A scoping review of health-related stigma outcomes for high-burden diseases in low- and middle-income countries [post_excerpt] => [post_status] => publish [comment_status] => closed [ping_status] => closed [post_password] => [post_name] => a-scoping-review-of-health-related-stigma-outcomes-for-high-burden-diseases-in-low-and-middle-income-countries [to_ping] => [pinged] => [post_modified] => 2021-04-06 11:45:01 [post_modified_gmt] => 2021-04-06 15:45:01 [post_content_filtered] => [post_parent] => 0 [guid] => https://sshiftb.org/?post_type=resources&p=1467 [menu_order] => 0 [post_type] => resources [post_mime_type] => [comment_count] => 0 [filter] => raw ) [7] => WP_Post Object ( [ID] => 1466 [post_author] => 4 [post_date] => 2021-04-06 11:42:30 [post_date_gmt] => 2021-04-06 15:42:30 [post_content] =>

Abstract

Stigma in health facilities undermines diagnosis, treatment, and successful health outcomes. Addressing stigma is fundamental to delivering quality healthcare and achieving optimal health. This correspondence article seeks to assess how developments over the past 5 years have contributed to the state of programmatic knowledge—both approaches and methods—regarding interventions to reduce stigma in health facilities, and explores the potential to concurrently address multiple health condition stigmas. It is supported by findings from a systematic review of published articles indexed in PubMed, Psychinfo and Web of Science, and in the United States Agency for International Development’s Development Experience Clearinghouse, which was conducted in February 2018 and restricted to the past 5 years. Forty-two studies met inclusion criteria and provided insight on interventions to reduce HIV, mental illness, or substance abuse stigma. Multiple common approaches to address stigma in health facilities emerged, which were implemented in a variety of ways. The literature search identified key gaps including a dearth of stigma reduction interventions in health facilities that focus on tuberculosis, diabetes, leprosy, or cancer; target multiple cadres of staff or multiple ecological levels; leverage interactive technology; or address stigma experienced by health workers. Preliminary results from ongoing innovative responses to these gaps are also described. The current evidence base of stigma reduction in health facilities provides a solid foundation to develop and implement interventions. However, gaps exist and merit further work. Future investment in health facility stigma reduction should prioritize the involvement of clients living with the stigmatized condition or behavior and health workers living with stigmatized conditions and should address both individual and structural level stigma. [post_title] => Stigma in health facilities: why it matters and how we can change it [post_excerpt] => [post_status] => publish [comment_status] => closed [ping_status] => closed [post_password] => [post_name] => stigma-in-health-facilities-why-it-matters-and-how-we-can-change-it [to_ping] => [pinged] => [post_modified] => 2021-04-06 11:42:30 [post_modified_gmt] => 2021-04-06 15:42:30 [post_content_filtered] => [post_parent] => 0 [guid] => https://sshiftb.org/?post_type=resources&p=1466 [menu_order] => 0 [post_type] => resources [post_mime_type] => [comment_count] => 0 [filter] => raw ) [8] => WP_Post Object ( [ID] => 1465 [post_author] => 4 [post_date] => 2021-04-06 11:33:55 [post_date_gmt] => 2021-04-06 15:33:55 [post_content] =>

Abstract

Community-led tuberculosis (TB) active case finding is widely promoted, heavily funded, but many efforts fail to meet expectations. The underlying reasons why TB symptom screening programs underperform are poorly understood. This study examines Nigerian stakeholders’ insights to characterize the mechanisms, enabling structures and influences that lead programs to succeed or fail.

Eight focus group discussions were held with Community Health Workers (CWs) from four models of community-based TB screening and referral. In-depth interviews were conducted with 2 State TB program managers, 8 Community based organizations (CBOs), and 6 state TB and Leprosy Local Government supervisors. Transcripts were coded using Framework Analysis to assess how divergent understandings of CWs’ roles, expectations, as well as design, political and structural factors contributed to the observed underperformance.

Altruism, religious faith, passion, and commitment to the health and well-being of their communities were reasons CWs gave for starting TB symptom screening and referral. Yet politicized or donor-driven CWs' selection processes at times yielded implementers without a firm grounding in TB or the social, cultural, and physical terrain. CWs encountered suspicion, stigma, and hostility in both health facilities and communities. As the interface between the TB program and communities, CWs often bore the brunt of frustrations with inadequate TB services and CBO/iNGO collaboration. Some CWs expended their own social and financial capital to cover gaps in the active case finding (ACF) programs and public health services or curtailed their screening activities.

Effective community-led TB active case finding is challenging to design, implement and sustain. Contrary to conventional wisdom, CWs did not experience it as inherently empowering. Sustainable, supportive models that combine meaningful engagement for communities with effective program stewardship and governance are needed. Crucially effective and successful implementation of community-based TB screening and referral requires a functional public health system to which to refer.

[post_title] => Community health care workers in pursuit of TB: Discourses and dilemmas [post_excerpt] => [post_status] => publish [comment_status] => closed [ping_status] => closed [post_password] => [post_name] => community-health-care-workers-in-pursuit-of-tb-discourses-and-dilemmas [to_ping] => [pinged] => [post_modified] => 2021-04-06 11:33:55 [post_modified_gmt] => 2021-04-06 15:33:55 [post_content_filtered] => [post_parent] => 0 [guid] => https://sshiftb.org/?post_type=resources&p=1465 [menu_order] => 0 [post_type] => resources [post_mime_type] => [comment_count] => 0 [filter] => raw ) [9] => WP_Post Object ( [ID] => 1464 [post_author] => 4 [post_date] => 2021-04-06 11:29:29 [post_date_gmt] => 2021-04-06 15:29:29 [post_content] =>

Book Content Overview

Chapter 1 introduces readers to stigma theory and some basic definitions of types of stigma. Chapter 2 (methodology) offers an overview of the scientific and operational considerations for matching your stigma measurement method to your question. Chapter 3 teaches formative qualitative research techniques to and out why the TB stigma takes a particular form, where the stigma comes from, and how stigma operates in your setting. Chapter 4 focuses on the measurement of TB stigma at the community level. This chapter details special considerations for embedding TB stigma measures in household surveys (e.g., scale length), and in settings with concentrated vs. generalized HIV epidemics. Chapter 5 focuses on measurement of TB discriminatory attitudes and behaviors in institutions such as prisons, schools, and health facilities, and has a special focus on measuring enacted TB stigma (discriminatory behaviors) through observational methods. The TB stigma literature has focused more on discrimination and disparagement of individual TB patients and less on the structural forms of discrimination. Chapter 6 covers the measurement of structural stigma. Chapter 7 teaches the basic principles of TB stigma measurement among TB patients. This is a relatively well-developed field with validated TB stigma scales robust in a variety of settings. Nevertheless, there are statistical and sampling challenges that require special consideration. Techniques for measuring secondary stigma are introduced in Chapter 8. This chapter describes the best practices for measuring stigma among healthcare workers (HCW), family members, and those in TB-affected industries. HCW stigma measurement is a high priority because HCW are often stigmatized for their vital TB care work, and yet may simultaneously mistreat TB patients. Chapter 9 explores how to measure TB stigma among socially networked populations who are already marginalized and socially excluded for other reasons. It outlines the efforts required to obtain reliable and unbiased estimates. State-of-the-art methods for capturing self-stigma, resilience, and self-efficacy are covered in Chapter 10. It is vital to measure the strengths and forms of 8resistance of people affected by TB. Documenting how some groups successfully detect stigma can inform interventions. Chapter 11 teaches how to deconstruct the language of TB programs to identify stigmatizing rhetoric and discourse. This chapter explores methods for policy analysis to pinpoint stigma embedded in norms and guidelines. Chapter 12 describes how to engage civil society and TB patients meaningfully in TB stigma measurement efforts. This text provides useful tips on participatory strategies that prevent further stigmatization and ensure dignity. Chapter 13 lays out the methodological foundations for incorporating the costs of TB stigma and social disadvantage into a cost-effectiveness analysis. Policy and strategy debates in TB control may have unintended consequences that should be anticipated. Chapter 14 involves intersectional and compound stigmas, such as the double stigma of TB/HIV. It is widely understood that TB stigma can be enmeshed with other kinds of social exclusions and marginalities. This creates analytical challenges that must be managed carefully to prevent bias and confusion. Chapter 15 describes how to study the impact of TB on complex behaviors, such as health-seeking, adherence, and mortality. This is a field of particular interest to TB programs seeking to understand the impact of TB stigma on their program. Chapter 16 gives concrete advice for those who want to develop and validate their own TB stigma scales. Chapter 17 gives step-by-step instructions for analyzing qualitative data from formative stigma research.

[post_title] => TB StigmaMeasurement Guidance [post_excerpt] => [post_status] => publish [comment_status] => closed [ping_status] => closed [post_password] => [post_name] => tb-stigmameasurement-guidance [to_ping] => [pinged] => [post_modified] => 2021-04-06 11:29:29 [post_modified_gmt] => 2021-04-06 15:29:29 [post_content_filtered] => [post_parent] => 0 [guid] => https://sshiftb.org/?post_type=resources&p=1464 [menu_order] => 0 [post_type] => resources [post_mime_type] => [comment_count] => 0 [filter] => raw ) ) [post_count] => 10 [current_post] => -1 [in_the_loop] => [post] => WP_Post Object ( [ID] => 1475 [post_author] => 4 [post_date] => 2021-04-06 12:49:37 [post_date_gmt] => 2021-04-06 16:49:37 [post_content] =>

Abstract

Background

Methods

Results

Conclusion

[post_title] => “Before Xpert I only had my expertise”: A qualitative study on the utilization and effects of Xpert technology among pediatricians in 4 Indian cities [post_excerpt] => [post_status] => publish [comment_status] => closed [ping_status] => closed [post_password] => [post_name] => before-xpert-i-only-had-my-expertise-a-qualitative-study-on-the-utilization-and-effects-of-xpert-technology-among-pediatricians-in-4-indian-cities [to_ping] => [pinged] => [post_modified] => 2021-04-06 12:50:49 [post_modified_gmt] => 2021-04-06 16:50:49 [post_content_filtered] => [post_parent] => 0 [guid] => https://sshiftb.org/?post_type=resources&p=1475 [menu_order] => 0 [post_type] => resources [post_mime_type] => [comment_count] => 0 [filter] => raw ) [comment_count] => 0 [current_comment] => -1 [found_posts] => 65 [max_num_pages] => 7 [max_num_comment_pages] => 0 [is_single] => [is_preview] => [is_page] => [is_archive] => 1 [is_date] => [is_year] => [is_month] => [is_day] => [is_time] => [is_author] => [is_category] => [is_tag] => [is_tax] => [is_search] => [is_feed] => [is_comment_feed] => [is_trackback] => [is_home] => [is_privacy_policy] => [is_404] => [is_embed] => [is_paged] => 1 [is_admin] => [is_attachment] => [is_singular] => [is_robots] => [is_favicon] => [is_posts_page] => [is_post_type_archive] => 1 [query_vars_hash:WP_Query:private] => b09ff30083984145b1da31f5c035c786 [query_vars_changed:WP_Query:private] => [thumbnails_cached] => [stopwords:WP_Query:private] => [compat_fields:WP_Query:private] => Array ( [0] => query_vars_hash [1] => query_vars_changed ) [compat_methods:WP_Query:private] => Array ( [0] => init_query_flags [1] => parse_tax_query ) )

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Here are some resources relevant to social science work in TB, many of which involve contributors of SSHIFTB. Please contact us if you would like to submit a new resource.

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“Before Xpert I only had my expertise”: A qualitative study on the utilization and effects of Xpert technology among pediatricians in 4 Indian cities

Mohit’s Pharmakon: Symptom, Rotational Bodies, and Pharmaceuticals in Rural Rajasthan

Dr. Ram’s triage: Categorization, speculation, and granting access to global health technologies in Indian private clinics

Dr. Zahir’s dilemma: money and morals in India’s private medical networks

Blind Spot How Neoliberalism Infiltrated Global Health

Acceptability of masking and patient separation to control nosocomial Tuberculosis in Uganda: A qualitative study

A scoping review of health-related stigma outcomes for high-burden diseases in low- and middle-income countries

Stigma in health facilities: why it matters and how we can change it

Community health care workers in pursuit of TB: Discourses and dilemmas

TB StigmaMeasurement Guidance

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