Transnational medical research has become a common feature in many parts of Africa. This paper explores the contribution such activity makes to the social and economic lives of those involved, including both trial subjects and local staff. By considering the value of the ‘exposure’ that involvement brings to staff and research participants, we reflect on the conversion of scientific knowledge into practical knowledge and its value to sustaining precarious livelihoods in an economically fragile city. We consider the interplay between science and sociality and argue for a need to take seriously the circulation of scientific knowledge beyond the confines of expert spaces. December 2009. In an African city two women prepare to leave their houses for the day. Emily,Meanwhile, in her mud-walled bedsit, Jennipher, a research participant in an HIV prevention trial, prepares breakfast for her husband, who does roadside radio repairs. The charcoal briquettes she makes from coal dust and clay to sell to her neighbours are piled in the corner. Jennipher packs a bag with a cloth and flask of porridge for her toddler who is freshly bathed, powdered and wearing a frilly dress. Today Jennipher is taking her daughter to the research centre for their final visit. She plans to ask the doctor to write her a recommendation letter for a peer-education position she has seen advertised at an HIV Treatment Centre. Jennipher did not complete school and hopes a note from the doctor describing her knowledge about HIV, acquired through her trial participation, will suffice. She grabs her research participant ID card and walks to the centre. Roadside billboards advise her to carry a condom, call abroad from 10 bob a minute and invest in shares. She passes signposts for various HIV-related NGOs and tents used for mobile HIV testing. She enters the ‘Obama Gate’ to the public hospital compound. There she passes Emily, the study nurse, alighting from her minibus. They catch each other's eye and smile, as both display their ID cards to gain entrance to the guarded research centre within.Emily and Jennipher live, work and plan for their families' futures in uncertain situations in an African city. In doing so, they both engage with scientific knowledge involved in the practices of HIV/AIDS research. One is a research participant in a trial to reduce mother-to-child transmission of HIV conducted by a parastatal National Clinical Research Organisation (NCRO) in collaboration with a Central Health Agency (CHA) from the Global North.Many parts of Africa are experiencing the profound impact of large-scale biomedical research programmes, intertwined with much larger transnational HIV/AIDS interventions Crane , both prWe use ‘scientific knowledge’ as shorthand for knowledge that results from scientific work in a given place, and that retains connections or reference to its scientific origins. We are not focusing here on the abstraction of ‘Science’ as in the making and circulation of scientific facts in a global scientific community. Anthropology already has a strong tradition of prising open the sociality of making scientific facts  the same, while its ‘context’ shifts. If the knowledge does change along the way, this reflects simple distortion due to insufficient communication  at the NCRO/CHA field-station, one of the largest and most prolific sites of bio-scientific production in sub-Saharan Africa. Located in a city with a population of With at least four other major transnational medical research organisations in addition to NCRO/CHA, as well as numerous smaller operations and university research departments, medical research activity permeates this city.Transnational collaborative research began here after World War Two. NCRO/CHA collaboration pre-dates the HIV epidemic by 20 or so years – malaria is another of the region's disease burdens – but has rapidly intensified and professionalised since. This also reflects a wider HIV economy. By 2011 there were 117 NGOs with headquarters in the city. Fifty per cent reported HIV as their main activity.Our anthropological study was referred to as the ‘trial community study’, reflecting the idea that all those connected by science work – academics, funding agencies, policymakers, government doctors, researchers, participants, their relatives and the wider public – constitute a ‘community’, albeit a shifting, heterogeneous community bound together by multiple over-lapping networks across levels of scale Geissler . Our ethOur team consisted of ethnographers and assistants from Africa and the Global North, involved at different times. We lived in various city suburbs, including gated communities popular with expatriates and estates popular with science workers and participants. From these spaces we observed not just the specificity of NCRO/CHA in which we were embedded but also the wider landscape of HIV research and intervention in the city.We interviewed over 100 staff involved in NCRO/CHA HIV research projects and conducted extensive, repeated, interviews with 89 HIV+ women participating in a study to prevent mother-to-child HIV transmission. The trial involved over 500 women recruited from antenatal care centres upon HIV diagnosis and followed for two years after delivery. We began interviewing these participants towards the close of the study, when some were still attending the clinic, and others had already ‘exited’. We followed several participants after the end of their participation, visiting them at their (often shifting) homes, and joining them during their visits to public HIV treatment centres.Being here [NCRO/CHA] I consider a step forward. It's a kind of an exposure; I am able to develop myself. Our interest in the movements of scientific knowledge, linking people's daily life in the city, personal and professional biographies and scientific work, found an apt expression in a term oft-cited by our informants: ‘exposure’. Many informants described how participation in medical research provided them with exposure to new knowledge, including medical, pharmaceutical and technical expertise, as well as exposure to organisations and places, people and lifestyles, processes and connections.For staff, this included opportunities for formal higher education, but also access to less formal knowledge: exposure to new ways of thinking, technologies, practices and networks, and imaginaries of futures engendered by this exposure. A third of staff directly cited ‘exposure’ as a key benefit of working in this leading transnational research organisation. Others used different words to portray their exposure to formal and informal knowledge through their employment. They spoke of meeting new kinds of people and of learning how to interact with them (e.g. foreign scientists). They referenced previously unseen connections and procedures (e.g. grant mechanisms), hitherto inaccessible places  and objects and resources previously out of reach – such as computing, internet or state-of-the-art laboratory equipment.‘Exposure’ thus offers itself as a broader cover for this much coveted mode of partaking in scientific knowledge. Working with NCRO/CHA – the leading research organisation in the region, as well as a key site of HIV policymaking and intervention – afforded staff the ideal setting to get exposed, partly because of the cutting-edge knowledge that research work produced, and partly because of the extraordinary power, resources and expertise invested in this collaboration. Exposure, as a rather nebulous form of knowledge-making, is particularly sought after and indeed vital in the contemporary post-HIV economy. In this new economy, formal professional training and higher education are somewhat devalued, and rapidly shifting knowledge-clusters, shaped by particular institutions, funding trends and fashions  are vital for finding employment and sustenance.However, being ‘exposed’ also echoes older local meanings, sharing connotations with a term common since colonial occupation in many parts of Africa: ‘enlightened’ Mayer . LinkingExposure was not confined to staff. Research participants also sometimes deployed this term to describe knowledge – particularly around HIV self-care – gained through trial participation. But becoming exposed is somewhat different to the notion of being ‘empowered’ prevalent in HIV policy narratives about self-care Prince , which hThe value attributed to exposure in the narratives of research staff and participants, therefore, cannot be divorced from concrete material concerns with making-a-living in a city with one of the highest HIV prevalences in Africa, a widening gap between the few in employment and the many outside and an ever-present sense of precariousness. When we look at how researchers and participants, such as the two described in the opening of this paper, make use of scientific knowledge we are also asking about what it is that makes a life. How do the people whose lives we have caught a glimpse of in our fieldwork imagine a meaningful life for themselves, their dependants and fellow citizens? What is it that drives them forward against the odds?Securing a relatively stable existence in this city is challenging for many. So far we have referenced ‘exposure’ in relation to opportunity, but there is another kind of exposure faced by people: exposure to uncertainty and danger. Poverty, hunger, accidents, violence, illness and particularly, in the parlance of HIV research and interventions, ‘exposure’ to HIV infection. HIV prevalence is double the national estimate. Many people depend for their daily survival upon antiretroviral treatment, which has been provided free since 2005 through public facilities but which still reaches only part of the HIV+ population, and has important limitations in terms of organisation, diagnostic facilities and drug availability. Risk of exposure to HIV is a felt presence for everyone, as well as, of course, the motivation and precondition for the high intensity of HIV research.Daily efforts to live in spite of HIV epitomise a wider economy of uncertainty: an economic order in which life has to be sustained day-by-day and where it never is certain whether needs – medical treatment, food or housing, children's school fees – can be satisfied the next day. Regular jobs as industrial workers or government employees – once a safe option for every school leaver – have become an exception for younger people, while school leaving certificates have lost much of their former value. Most people work in the informal or ‘jua kali’ (lit.: exposed to the hardship of the ‘fierce sun’) sector without a regular employer or stable income, and with minimal capital turnover or overheads. ‘Jua kali’ work was originally associated with making and repairing cheap, useful products outside traditional factory settings, usually along the roadside, but has grown to include all those ‘hustling’ for a living by, for example, hawking clothes, selling small quantities of vegetables or otherwise creatively trying to find something to do when locked out of formal employment structures  supported themselves, or were supported by husbands, through ‘jua kali’ work, such as tailoring, ‘mobile’ hair plaiting, or selling vegetables in minute quantities. Husbands' work involved unskilled construction or touting for buses. All these ‘small small business’ activities tended to be short-lived and shifting.Of the few trial participants not involved in such work, three were supported by relatives and six were living off their domestic farms. Five had husbands with more regular employment: as drivers, a shop assistant and a printer's assistant. None of these involved regular payments. There were two nursery school teachers and one school secretary, all in low-status private schools, receiving inconsistent cash-in-hand payments. One mother was enrolled in teacher-training, and one a government primary school teacher. This mother and another who was a government driver were the only mothers whose families had any contractual link to a formal organisational structure and accessed a regular salary paid into a bank account.Many mothers also experienced social insecurity. Few could describe their marital situations as stable and not infrequently marital arrangement changed during trial participation: there were many widows, second or third wives, women describing themselves as separated from their husbands, single mothers and wives out of formal wedlock, who could not count on husbands. Understandably, these mothers valued what study participation could offer them in terms of free, good quality healthcare, occasional material benefits such as water pots, transport reimbursement and generally being taken care of.These small-value transfers are part of a range of new opportunities available to poor, especially HIV+, people within the local HIV economy. Boundaries between research and intervention are porous, since many scientific and academic institutions have expanded from clinical trials into implementation and evaluation. NGOs and ‘Community Based Organisations’ have become a dominant entrepreneurial model providing diverse economic opportunities. Some of these involve short-term contracts creating new specialisations in novel forms of expertise like community mobilisation and representation, quality assurance, participant retention etc., which in turn have generated high demand for training and certificates from new educational institutions providing certification in ‘HIV Counselling and Testing’ or simply ‘Community Work’. While employment in the non-governmental HIV sector is limited to those with formal education, high motivation and some good luck – and connections and access to information (‘exposure’) – many other people try to benefit from the HIV funds that circulate through today's urban economy through even less stable, ‘jua kali’-style activities, including providing services, housing and transport, as well as various forms of ‘volunteering’ such research participation . The staff we interviewed are leading representatives of this class. They are all secondary school graduates and include medical doctors, nurses and laboratory technologists, and others with more specific skills such as trial mobilisation, or HIV testing and counselling. Competition for positions is high – with 50–100 applicants even for menial jobs. Previous experience in research or NGOs is an essential asset, documented in candidates' thick portfolios of certificates. In comparison to many city residents, staff are already ‘exposed’. Their employment provides them with a degree of security, including written contracts, salaries paid into bank accounts, and health insurance.However, in some respects they are in a very different position to the original, post-independence ‘working classes’ of teachers and civil servants; their parents' generation (the ‘Enlightened’). While these had spent most of their lives working on permanent pensionable contracts with government ministries, NCRO/CHA staff have at best one-year contracts, with higher perks but without lasting tenure and secure retirement, and their salaries and promotion depends upon foreign institutions with shifting expatriate staff and changing policies and budgets.Fundamental uncertainty therefore applies thus to everyone in the city. In some respects, the line between an HIV researcher and a woman surviving on ARVs and selling tomatoes by the piece is porous; both lives are contingent on the vagaries of international donors. Even those who, from a poor participant's perspective, have ‘made it’ into employment remain ‘exposed’ to uncertainty. Transnational medical research exists in a state of permanent temporariness – or ongoing boom and bust – dictated by the politics of international funding, project cycles and of course the science and urgency of the disease burden itself. Staff, thus, expressed considerable disquiet around the time of the annual renewal of one-year contracts and the completion of research studies. If a contract ends or a new study does not immediately follow a completed one, private medical insurance is stopped, cars are sold and children's school fees are at risk. To enhance stability and diversify options staff, like participants, run (as noted in the opening vignette) businesses on the side. These range from the substantial or skilled, investing in shops, farmland and rental properties, to the same ‘small small’ businesses as their participants, i.e. hawking clothes, vegetables, soda and mobile phone scratch-cards to colleagues.What most current economic activities in this city have in common, then – including even HIV research employment – is short-term temporality, dependency upon outside funding sources and resulting uncertainty. As a common expression in the city puts it, one is ‘just trying’. While direct, literal struggle for survival certainly is not the condition of life for everybody, this extreme – and the spectre of death as the ultimate certainty underlying it – affects almost everybody's life. Everybody has relatives living under such conditions, and fulfils attendant responsibilities, and in the absence of social security, many are at risk of sinking to the level of mere survival. Life is a constant process of trying, of pursuing possibilities without knowing their outcomes  or ‘I got really inspired and said “I want to be an international policymaker!”’ . Although such statements tended to be accompanied by ironic laughter there was an idea, supported by widely narrated rags-to-PhD biographies within the organisation, that such distant places could be reached through careful step-by-step planning and effort.placement, a position that opens up future opportunity, and provides an overview of networks and the terrain of possibility, as well as contact with others who could provide strategic and academic advice. This sort of learning is not simply a matter of ‘who you know’, but knowing where to look, and when, and also of how to make oneself known, visible to opportunity, potential supporters and gatekeepers.The field station offered some limited funding towards diplomas, Masters and even PhD studies. However, relatively stable wages and a yearly gratuity, made self-funding an option and many staff were enrolled in privately paid academic evening courses. NCRO/CHA also provided invaluable infrastructure for distance learning: high speed internet, new computers, professional mail addresses, subscriptions to literature databases that few African university students can access, and research data for thesis work. To utilise these resources for their ‘schoolwork’ and other assignments, staff often stayed late at their offices. Beyond material support, this international, high-aiming workplace also provided crucial exposure to knowledge about courses, their content, reputation and employability potential in a rapidly shifting market of HIV expertise, application procedures, deadlines, styles and references. NCRO/CHA thus provides a good Some directly research-relevant knowledge, such as computer skills, lab techniques, technical terminology or clinical handling procedures, was conveyed as part of institutional ‘capacity building’ by senior staff or external experts or, in the case of laboratory equipment, by the manufacturers. Other skills, notably in scientific dissemination, were acquired through paper-development workshops or conference presentation rehearsals.Most staff's scientific knowledge, however, was gathered informally, through conversations, or observing others. Here, the concept of ‘exposure’ with its connotations of learning through being somewhere is particularly apt. Large organisations, notably transnational ones, develop their own sociality and work-related cultures; and working for such organisations impacts people's lives through formal and informal learning processes and habitual inculcation to work ethics Wright . In NCRO‘Being with’ NCRO/CHA therefore involved habits and connections, ranging from preferred social venues and shopping places, gained and lost friends and social networking, to the embodied dimensions of speech, posture, hairstyle and dress. Some of these aspects remained implicit, others were consciously experienced, and either valued as exposure, or registered with some irritation; thus, some staff recalled how, during the initial days of their employment, their dressing styles and comportment had made them feel out of place among the well-groomed staff: ‘I could hear my flip-flops in the staircase, among all these high heels’ . The same staff member likened the totality of the experience of entering the new work culture as: ‘You feel like you are in another world, you are in another country.’Pushing this analogy further, informal learning within this workplace also involved getting to know new people at the workplace and beyond – globally and locally: ‘I have exposure. I have met so many people that I never knew that I could meet in the world of HIV/AIDS. I have talked to them. I have shared with them. I have learned a lot' .The pleasure that this staff member – who otherwise was particularly critical of the inequalities and shortcomings of transnational collaboration, even evoking its ‘colonial’ continuities – took in making connections across continents, national boundaries, race and class, was reflected by his screensaver displays, depicting him in various exotic locations, sharing moments of conviviality and touristic experiences with world-leading HIV scientists at international conferences.Thus exposure to scientific knowledge and attendant modes of being – in conferences, seminars, planning meetings and discussions with senior staff and overseas experts – implies a process of becoming part of a larger world: ‘We have access to literature materials about youth intervention, about research work that is being done in many places, we are in a sense being fitted in the world map of adolescent sexual reproductive health' .mobility as in the case of staff given the chance to travel to international conferences. Such opportunities were highly valued, not just for the chance to mingle with experts but also to see and experience more of the world and exchange ideas with others in similar situations. Under wider conditions of globalisation, mobility itself is often associated with the realisation of value. Some of the value realised or, we could say converted through scientific knowledge, was less lofty than the exchange of scientific ideas. One staff member for example, was initiated to the global clothes trade when talking with colleagues at a conference in Thailand, enabling her subsequently to set up a successful clothes shop in the city. A few staff even ‘got lost’ overseas, using temporary visas obtained through international conference participation to start new, potentially just as uncertain, lives abroad.Sometimes exposure to the wider world was through literal For the many who remained within Africa, these wider spaces and collectives, beyond the immediately accessible, were demarcated by senior staff's teleconferencing and international travel, data-faxing to research network headquarters, equipment supplies and maintenance by multinational firms, international technical standards and guidelines and reliance upon foreign grants and funders. It was present, for example, in the common reference to the CHA's Northern headquarters, as in ‘we are waiting for [HQ's] response’, and related turns of phrase like ‘back there’, ‘out here’, ‘coming down/out’, with implications of a global, hierarchically structured space, or in the disembodied voice of a foreign ‘principal investigator’ emanating from a mobile phone at the centre of the meeting table. The imaginary of other  places combined with the value placed on further education, noted above, into a specific vision of moving forward in life, out of one's present condition towards new places.CHA has a particular place within African HIV and bioscience landscapes – conducting not only large-scale, world leading research, but also shaping health policy across the continent, and implementing HIV care and treatment through government institutions. Attachment to NCRO/CHA provides an opportunity to work and learn in an environment that represents, like no other in Africa, the cutting edge of scientific – as well as clinical – expertise and possibility. It is the best place to get reliable information on the latest global scientific developments, and develop new ways of thinking about the world – a site from which both the world and one's place in it, and oneself, are transformed.et al. I've learnt about good clinical practice, about how to do certain things in research… Research is very strict in the ways that they do things. So, actually it builds discipline in you, I think I have loved that. The recognition of the state of the art, inherently influential positioning of NCRO/CHA's scientific knowledge was not simply a matter of personal career advancement, good salaries or per diems. It also speaks of a search for innovation, potency, trustworthy knowledge and global standards, and reflects staff's curiosity and yearning for job satisfaction: being able to do what one knows one could and should do .The metaphor of ‘graduation’ – a particularly sought after social occasion in this part of Africa, immortalised by photographs displayed in every living room – underlines the forward-moving nature of knowledge, and it implies a vision where NCRO/CHA is a step on the way rather than a final destination. Employment with research is time-limited and will end, the positive outcome of which is to move ahead to a more permanent or at least even better paid job. The particular attraction of this knowledge, then, lies in its convertibility and transportability. It is of value in the city's HIV economy, which involves related organisational structures and similar procedures and idioms, such as notions of participant autonomy, voluntarism, standard operating practices, evaluation, participant flow, consent etc. which have travelled within the organisational networks of the HIV economy.However, like the future after graduation, conversion is not always straightforward. The success of such movement depends upon the market situation, and upon the nature of the knowledge. In spite of the booming HIV economy there are increasingly many knowledgeable workers and competition among them is getting harder. When this is coupled with the ongoing boom and bust nature of project-based HIV research work, there were times when the harder, more painful, edges of the search for a better life revealed themselves in competition for roles in new projects. When some staff lost out mutters of patronage, sexual favours and corruption surfaced and the ethos of conviviality was harder to maintain.But sometimes I say CHA can cheat you until you forget that out there in the world, everything is not like CHA. It makes you feel so comfortable in your work, that it might even hamper your creativity; you might start thinking like a non-African and look at the world like a non-African. But my own perspective is, that if you are in Africa and you are dealing with Africans you have to think like an African.NCRO/CHA's staff's pursuit of scientific knowledge in their city's leading institution for knowledge making and dispersal, and their emphasis on the value and marketability of such knowledge may, therefore, seem individualistic and self-serving. This recalls other ethnographic descriptions of African donor-funded AIDS programmes, which according to their Northern authors are inhabited by ‘aspiring’ elites involved in ‘hunting and gathering in a terrain of AIDS NGO projects’ .In addition, most staff have taken on responsibilities for orphaned children of their kin. Thus, one nurse described how she is ‘pulling’ family members ‘up behind her’ as she progresses within medical research. Her family was decimated by HIV leaving many dependants in her rural home. Her aunt sponsored her secondary education and certificate in nursing, hoping she might become a future stabilising influence in the family. After experiences in mission hospitals she was employed by NCRO/CHA and after initially self-funding her further education, she eventually received sponsorship for Masters studies. Using her salary, the annual gratuity, and per diems saved from conferences, each year she gradually built up the number of relatives whose education she sponsors. Underlining the value of education, she compared herself to her brother who stayed home, married young, and now has several children. Yet she convinced even him to go back to finish school and start this process for himself and his own dependants. Other staff, too, talked about this social conversion of knowledge with pride: ‘I can be proud because I am now furthering my education, and then I am supporting some other people, and I also intend or plan to support a pupil next year, who is joining secondary. So of course I account those as achievements' .Often, like in the above case, this process of conveying knowledge starts as soon as one earns a salary. This is a tough and uncertain effort. It involves careful budgeting, saving and triage, as well as facing unreasonable expectations and the possibility of educational failure. Working at NCRO/CHA is particularly useful, not just because of the higher wages, but because staff know what knowledge counts where and where best to attain it.As discussed earlier, the increase in HIV funding and the associated growth in income opportunities has created a generalised imaginary of possibilities among all city residents. The HIV+ mothers we interviewed represent – in the most part – a distinctly different economic and social class to the staff discussed above. Possibilities open to them for exposure and career development are, therefore, markedly reduced. However, there was one area where study participation, in conjunction with one's biological status as HIV+, was an entry point to a form of employment, albeit often as inconsistently paid ‘volunteers’. This was the field of ‘peer-education’.Peer-education is the use of HIV+ ‘peers’ for counselling, care and general assistance in both research and treatment. Peer-education with HIV treatment centres represents a particular kind of ‘voluntary’ labour in this city. While officially ‘volunteer’ positions, most of the time volunteers receive a regular monthly payment and sign contracts. More significantly, volunteers are exposed to the formal workings of the organisation. They have to adhere to specific working hours, attend staff meetings and, to centre clients, appear as regular staff. In their day-to-day encounters with clients, they are holders of expert knowledge on HIV. Occasionally chances present themselves for some training or additional paid work, such as mobilising during mobile VCT sessions. Some peer-educators can make the transition to a formal contract as community health worker with the treatment centre, although this does require a school leaver's certificate.only actual employment held by any ex-study participants we interviewed.Seven of the 91 mothers we interviewed became peer-educators in HIV research or treatment programmes after they exited the study and before the end of our fieldwork. Three were employed on temporary contracts by the study itself to act as peer-educators to other participants. They were later absorbed as regular staff on other studies or moved on to better paid positions in external organisations. Others were working in various HIV treatment centres in the city and beyond. Peer-education as an economic opportunity for this group takes on significance in terms of both numbers and imagination when it is noted that this was, aside from one teacher and one government employee, the Study peer-educators were generally valued for providing tender care, and spoken of lovingly by other participants: ‘they were encouraging our hearts’. They also held a somewhat iconic status for both staff and participants – as a representation of what could be achieved and the potency of exposure. When one ex-study peer-educator who had obtained a car was spotted driving, both another participant and a doctor remarked on how well she was doing: ‘She is even driving a car now!’This particular peer-educator had used her salary to gain various counselling certificates and eventually applied for jobs in other organisations. In the time that we knew her she moved onwards and upwards several times, dropping ‘peer’ from her job title and developing a career trajectory indistinguishable, from that point on, from other staff. By 2016, when we shared a draft of this paper with her, she told us she was now a degree holder and social science interviewer herself with 8 years of experience working with various transnational research collaborations, commenting ‘It's amazing. I really never thought that I was a source of encouragement to many. I mean, it is just totally amazing.’ This peer-educator thus represents an imaginable but idealised and infrequent endpoint that creates a continuum between staff and participants in the circulation and conversion of scientific knowledge.I used to say to myself: ‘God, when my boy reaches six months I don't want to be here and I want the study to give me a job so that I can be able to give him formula.’ So that time I shared it with the  doctor. She encouraged me to go and see the Principal Investigator. So I carried my baby, I carried my umbrella and I was so tiny. When he was called, he came in the reception. It was so nice. He carried my umbrella and my bag. Then I explained to him what I wanted. He looked at my CV. There was a project I had done for a CBO and it really excited him.The study peer-educator described above seized upon her physical placement within the research organisation as an opportunity to capitalise on her exposure to people she might normally have not met:We used to share the [waiting room] bench … but it sometimes happens to many people that when somebody is employed she changes. I found out we can't rhyme together [anymore] so I just kept away. She was picked to be a peer-educator because she was suffering. I felt bad because everyone is in need. Should I also go and say my problem so I can be employed? But my legs were just heavy for me to go.This action – and subsequent changing trajectory of placements – was a source of inspiration that also, ironically, created some distance between her and some participants who couldn't make the same use of their placement in the trial:The importance of placement as a way of opening up further opportunity was also experienced by participants who became peer-educators in HIV treatment centres after the study ended. Like staff, by virtue of being in a space of activity in the field of HIV, they had occasional chances to gather useful information. Sometimes this worked in rather refracted ways. The study had created a self-help support group for participants and encouraged them to join both for emotional support and as an opportunity for talks and small training sessions . This inspired one mother to join a similar support group attached to her HIV treatment centre after exiting the study. There she became friends with one of the centre's existing peer-educators. When an advert was placed on the wall in the centre for new peer-educators, it was he who told her when and where to look.Study participants received no formal training in HIV knowledge. But informally, in the process of being a study subject, undergoing clinical procedures and receiving counselling, learning the rules of the study and sharing with other participants and study peer-educators, they did gain specific knowledge that was not only of lasting use as an HIV positive person, but also convertible into social advancement for those that became peer-educators. One of these participants described how she had been asked to explain the terms ‘adherence’ and ‘opportunistic infections’ when she interviewed for a volunteer job, terms she knew very well because the study had been strict on adherence and had encouraged participants to come to the clinic frequently to treat opportunistic infections. A treatment centre coordinator, in turn, told us that she had specifically asked another participant to become a peer-educator because she saw from her referral letter that she had taken part in a study and would therefore be ‘knowledgeable and disciplined’. The use of the term ‘discipline’ is important here. As role models for others peer-educators are expected to be experts in their own self-care.The convertibility of implicit study knowledge was made explicit when participants asked their study doctors to confirm their knowledge in writing. When one mother who later became a peer-educator at her treatment centre responded to an advertisement for community health workers shortly after the end of her study participation, she went, like several of her fellow hopeful ex-participants, to visit her study clinician because: ‘I wanted the doctor to write for me at least a certificate to say I am from the study and know something about HIV, because they wanted a school certificate and I don't have one.’Similarly, one of the ordinary study participants we visited proudly showed us her file of certificates, including a copy of her study referral letter  and her study ID card, side-by-side with her school records, letter of reference for a job as a petrol station attendant and the certificates for workshops on ‘HIV Home based care and nutrition’, ‘Memory book making’ and ‘Taking care of the elderly’ that she had participated in as a volunteer community health worker with a church-based NGO. This folder was a visible representation of her own valuation of the place and convertibility of scientific knowledge gained through study participation in her life.In school Maureen had dreamt of training as a nurse. But when her parents died she was left to look after her sister, forcing her to leave school. Rejected by relatives, she struggled to find somewhere to live. After telling a shopkeeper her life story, she got a job but was often sick. She informally married a ‘jua kali’ man who paid her hospital costs. When she became pregnant she found herself to be HIV+ during her first antenatal visit, where a NCRO/CHA staff recruited her for the trial. When she joined the study she knew nothing about HIV. Described as a ‘good participant’ by staff, after exiting the study she went to continue treatment at a donor-funded centre, where she joined a support group and befriended a peer-educator, who alerted her when they advertised for peer-educators. At interview she described her experiences in the research study and, as she proudly recalled, was able to answer confidently questions such as ‘Do you know the work of Septrin?’ She got the position and was paid the equivalent of one day's informal domestic cleaning work per day. Later, international funding was stopped but she continued working voluntarily because she thought this better than sitting in the house where she ‘might be forgotten’, invisible to other opportunities.She continued to learn the work of the centre, being deployed in the pharmacy, the records department, and helping in drug adherence training for HIV clients. She also benefitted from improved quality of medical care, having direct access to doctors and her patient file to make sure her lab results were returned in a timely fashion.She continuously hoped for employment: ‘So we thought maybe these people the way they are appreciating us they will just employ us.’ When she applied for a job tracing drug defaulters she went back to a NCRO/CHA study doctor to get a letter of recommendation based on her study participation. But she was eventually told by the treatment centre human resource manager that any employment would require a school leaver's certificate. She thus started secondary-school education at an evening school, partially sponsored by an expatriate researcher she had met during the study. Today she dreams of eventually getting her school certificate, becoming a community health worker or researcher and ensuring her dependants can go to school and beyond. This dream is a long way off. She is still working unpaid.Research participants' opportunities to convert knowledge are small and unsteady, compared with those of staff. But they can accumulate, as in the following case of a participant-turned-peer-educator:A smartly dressed client came to rearrange her next visit because she had a higher diploma exam in the capital city on that day. She encountered Maureen who, during the in-charge's absence, was registering clients and addressing queries. Carefully, and with quiet authority, Maureen told her this would not be possible. She explained the importance of the two-week visit after initiating ARVs, checking that drugs were working and monitoring side effects. She suggested the client should come early in the morning before travelling to the capital. Upset, the client tried to negotiate, but Maureen stood firm. Eventually the client left in a huff, saying that she might fly to the capital to get there in time for her expensive exams. In contrast Maureen, who walks to the clinic to save the bus fare, returned to work, her books for the first year of secondary school in a bag under the desk. ‘She probably won't come back’, she told us, ‘she doesn't understand the importance’.Maureen's story shows the diffuse and fractured nature of exposure and conversion of scientific knowledge, but also the potential of its cumulative effect – Maureen has moved on, at least a little, from where she started. It also shows its limitations and barriers, particularly related to socio-economic inequalities, captured in the following encounter between Maureen and a client at the treatment centre:Some of the processes of exposure and conversion described in relation to the peer-educators were also experienced by the participants who did not achieve such status. The most obvious is the exposure to knowledge about one's HIV status and self-care developed through study participation. One participant described this process – of despair when discovering her HIV status to learning that there was treatment, and that she could have an HIV-negative baby – within a terminology of moving from darkness to light: ‘By then I didn't know anything. I only knew that once you fall positive yours is only death. I was still in darkness. But they explained to me the benefit of taking the drugs and the study, now I just thought I could help the life of my unborn.’Much of this knowledge was circulated not through direct teaching or dissemination but through the social experiences mothers gained whilst waiting on the clinic benches. Here, mothers learned that there were others in their situation, and felt encouraged that they were not alone and could live a normal life.Producing an HIV-negative baby at the end of this HIV transmission prevention study could be seen as the ultimate conversion of scientific knowledge that participants could gain through study participation. In dissemination meetings the scientific results of the study – the very significant reduction in HIV+ babies – was thus celebrated as a scientific triumph but also a personal one, achieved through hard work, steep learning and strict adherence to the new knowledge. It was notable that when we visited those mothers whose babies had become HIV+ during the study, we generally did not find, as we had expected, scenes of despair and tragedy, but rather scenes of quiet hope, organised effort and loved children. These ‘exposed’ HIV+ children were being looked after by ‘exposed’ mothers, armed with new knowledge about how to make a life for themselves in this uncertain city.There was a myriad of other, small, ways that study mothers found to take something of value from study participation and use it beyond. A few mothers, for example, opted to join other studies when the chance arose, having seen the benefit; others used their experience of high quality care, as well as discussions with other mothers to make informed decisions about which post-study HIV treatment centre to attend, even occasionally changing centres or coming back to consult with study doctors over issues in their care. Here, the importance of making use of social connections in a healthcare system perceived as contingent on relationships and placement is highlighted ? Could one imagine then that transnational research programmes – many of which now look back at decades of local clinical trial work, and consequently generations of ‘exposed’ populations – actually become formal sites of public engagement with and teaching of science?et al. , should register itself as an independent body and act as a permanent filter between the city and any research project that wanted to work in it was repeated again and again in meetings. And in the concern of the supervisor who struggled to retain the capacity of ‘thinking like an African’, we see an ideal future dreamed as one where science in this city could/should be a centre positioned among centres, rather than a periphery or satellite of a centre in the Global north (see Moyi Okwaro and Geissler  and Lachet al.  for discet al. Our interviews and observations with African research workers and participants bring to view the value of ‘exposure’ to scientific knowledge in its broadest sense to those whose day-to-day labour and mutual collaboration are the foundation of transnational medical research. These effects are not limited to the long-term social good of scientific progress or to the immediate material benefits of trial participation, but extend to subject formation. Although we recognise that the structures of both global and local inequality and injustice within which medical research and healthcare operates exclude and stagnate as well as include and energise (see Sullivan both to the lives –sometimes the survival – of those working on the trial, and to the maintenance of the scientific production itself: without this process of extension, labouring for science – be it technical work or bodily participation – would be a lot less attractive to people living in the city. Without the benefits of exposure, the scientific production process would lose much of its privileged status among the employment opportunities in the city. Life science and everyday life are in this sense co-constituted, and the flows of scientific knowledge across the city link it all up and keep it alive. In African cities like this one, there is no clear separation of science and sociality. Transnational medical research has become a part of everyday social and economic life. In this city, it is no longer something new, imposed from outside, or somehow separate from ‘national’ everyday life. To staff and participants, it is, simply, part of life.It needs to be stressed that these conversions of scientific knowledge between different productive settings in the lives of the staff and participants are vital


Thematic analysis and triangulation of the data from parents, practitioners and young people, elicited interconnected and complex overarching themes. Young people could be both victim and perpetrator. The witnessing or experiencing of domestic aggression and violence raised the concept of ‘bystander children’. The impact of young people experiencing familial violence was underestimated by parents. For practitioners, the effects of working with domestic violence was shown to be significant - both positively and negatively.A small scale qualitative project, undertaken by an interdisciplinary domestic violence research group involving academic researchers and research assistants, with colleagues from Independent Domestic Abuse Services (IDAS), investigated youth aggression and violence against parents. Following the literature review, data was generated through several research conversations with young people ( Domestic violence and abuse touches all ages, cultures, and classes. According to an NSPCC study (2011), 12% of under 11 s, 18% aged 11–17 and 24% of those aged 18–42 have been exposed to domestic abuse between adults in their homes during childhood. Such exposure can have a negative impact upon young peoples’ health and wellbeing  to refer to familial and domestic violence . When we refer to youth, we mean young people aged 11–17. When using the term ‘practitioner’, these are professionals who work directly with victims and perpetrators of interpersonal or domestic abuse and violence, including statutory services and voluntary sector workers in support and guidance roles. We adopt the term Young people who use violence at home tend to perceive their parents as weak and ineffective and see themselves as lacking power , in particular those where aggression and violence feature, has operated largely through statutory and criminal justice channels and has been aimed at minimizing offending behavior. However, concerns have been raised in the US about this approach, with research evidence indicating that such programs fall short and provide inadequate support and interventions  and with practitioners (n = 5); a practitioner focus group (n = 8), and extended research conversations with young people (n = 2). Practitioner participants included police, social work, youth work, probation, and case workers from voluntary agencies. Interviews were undertaken with practitioner participants who were not able to attend a focus group meeting. The practitioner participant interviews and focus group took place on University premises. Parent and youth participants were recruited through IDAS. Their interviews took place in homes, school settings, or parental business settings. The parent and youth participants had previously taken part in a Respect program, delivered by IDAS. The program aims to change offending or unhelpful behaviors and elicit positive relational styles. The research conversations and interviews ranged between 30 and 90 min in length and enabled in-depth participant exploration of sensitive matters. The focus group lasted 90 min and was deemed to be an efficient way to capture a range of practitioner perspectives  based in a university and research assistants  based in the same university. The ARs interviewed the mothers, facilitated the focus group and interviewed practitioners, whilst a senior research assistant worked with the ARs and IDAS to devise content and structure for research conversations with young people  which impacted upon their perception of themselves in their work. As one person noted “…working with these sorts of people I go back to my own experiences as a child, of domestic violence. It occurred in my household; at the age of 5 I’d be lying in bed hearing [the violence]…”.“… no child is evil…when we came out the house, we were sat in the car and [co-worker] said to me ‘ I don’t think I can do this job anymore’ and I said ‘you can, we’ve just hit a little bit of a bad area, we will overcome this, but you’ve got to believe in yourself’”.Perceived public distrust of statutory bodies exerted a negative impact. One practitioner noted “If I had a pound for every time a parent said to me ‘you’re going to take my child’, I’d be a millionaire”. Being constantly subjected to the complexities and challenges of working with domestic aggression and violence took its toll, impacting upon practitioner perceptions of humanity, as well as their capacity for self-care. One reported “…it’s a murky world when you work with people who commit sexual offences and domestic violence, it colors your view of society”. Another spoke of a case where a mother had described her child as evil and poignantly recounted:This scenario epitomized the psychological and emotional trauma experienced by some practitioners working with youth-to-parent domestic violence cases. Paradoxically, there was concurrent recognition of the positive and reparative impact of their work, including delivering interventions that positively changed young people’s lives.“… he had violent headaches, he wet the bed, he had nightmares, he made himself sick a couple of times after eating, which was a really big worry…withdrawn and smashing things up…”.All of the practitioners referred to the way in which children and young people were captive bystanders in domestic violence contexts. They cannot escape and usually had heard or witnessed domestic violence, with no perceived exit or remission from the situation. George epitomized what some bystander children and young people are subjected to. George’s mother recalls how:Although George’s violent father was separated from his mother, he still spent time at his father’s, groomed by the lure of treats. He frequently witnessed his father being violent with his new partner. Having already lived through his mother being treated violently, he was further traumatized and began behaving violently towards his mother. Over time, the mother became aware of what was happening with the father, whilst concurrently George became disillusioned with his father’s empty promises. Contact with his father ceased. The situation came to a head when the father attempted to abduct George, resulting in the police and social services being called in.Few in-depth qualitative accounts of youth to parent domestic violence and abuse exist. This qualitative project offers three key findings that complement existing studies and contribute to the knowledge base on familial aggression and violence. Firstly, young people who are aggressive with their parent or caregiver are usually victims themselves, therefore it is inappropriate to pathologize them as ‘perpetrators’. Secondly, in the face of an aggressive or violent child, parents are far less resilient or competent than might be imagined. Here, the role of relational and communication skills programs – such as that developed in the UK by Respect and delivered by DVA agencies – are important. Thirdly, frontline practitioners working with children and adults exposed to domestic abuse and violence can experience vicarious trauma, as indicated by researchers in the field of trauma  involve parents in attempts to tackle CPV, and place emphasis on working with parental guilt, shame, self-care, and boundaries. Restorative programs place emphasis on working with parents to minimize their ‘shame cycle’ and feelings of helplessness, and to promote ‘healthy relationships’ in the family system. Ideally, agencies can offer sanctuary to both parents and children who are affected by familial violence, rather than have interventions delivered by statutory agencies; their involvement is needed when there are no other options. Parenting tool kits and supportive strategies would seem essential (Hillberg Interventions for youth to parent DVA currently in use in the UK (see for example, Respect Hillberg  to suppoHillberg . Whilst Hillberg  and servHillberg , ensurinwounded healer concept is recognized within Jungian psychological theories (Sedgwick Practitioners felt overstretched and vulnerable; especially when sole working with DVA cases. Challenges were compounded by a perceived lack of appropriate work-based support. Arguably, practitioner wellbeing and self-care should be a core consideration across agencies dealing with domestic and interpersonal abuse and violence. Furthermore, a lack of self-care could contribute to practitioner traumatization (Newell et al. Sedgwick . Used inSedgwick . InteresSedgwick . HoweverIn considering youth to parent DVA, most of the practitioners expressed concerns about the impact of social media upon young peoples’ behavior. However, research on the effect of web-based materials on abuse and violence is limited and inconclusive. Recent studies on the influence of social media on aggressive behavior indicate the importance of taking a rigorous and multi-dimensional approach to the issue Diamond .The project was an in-depth, small-scale qualitative study therefore findings cannot be generalized to wider populations. We need to extend and deepen our understanding of the relational dynamics of youth to parent aggression and violence and the specific relationship contexts in which they occur. In particular, the parent-child relationship and the complex terrain of self-agency, resilience, relational power and coping tactics in the face of complex familial violence, require further investigation. Further research investigating the youth-parent relationship is essential, as well as ongoing development and evaluation of interventions to innovate relational resilience and coping strategies for both young people and parents. Developing a more sophisticated understanding of youth to parent violence and abuse, whilst evolving a better understanding of prevailing social, political and cultural influences, is essential.


The aim of the review was to investigate whether an assessment of clinical significance can be related to specific drug-related problems (DRPs) and hence may assist in prioritizing individual categories of DRP categorization systems. The literature search using Google Scholar was performed for the period 1990 to 2013 and comprised primary research studies of clinical pharmacy interventions including DRP and clinical significance assessments. Two reviewers assessed the titles, abstracts, and full-text papers individually, and inclusion was determined by consensus. A total of 27 unique publications were included in the review. They had been conducted in 14 different countries and reported a large range of DRPs (71–5948). Five existing DRP categorisation systems were frequently used, and two methods employed to assess clinical significance were frequently reported. The present review could not establish a consistent relation between the DRP categories and the level of clinical significance. However, the categories “ADR” and possibly “Drug interaction” were often associated with an assessed high clinical significance, albeit they were infrequently identified in the studies. Hence, clinical significance assessments do not seem to be useful in prioritizing individual DRPs in the DRP categorization systems. Consequently, it may be necessary to reconsider our current approach for evaluating DRPs. Drug-related problems (DRPs) are associated with increased morbidity and health care costs, and identifying and addressing DRPs are essential tasks within the health care system ,2,3. VarDRPs may be identified and solved as a part of conducting medication reviews, which in practice, are often performed by clinical pharmacists in collaboration with physicians . When reHowever, none of the DRP categorization systems prioritise the individual categories—or indicate whether some categories are of a higher clinical importance. This information might be of value when implementing interventions addressing DRPs, as well as for evaluation purposes. An example of a DRP, which is frequently associated with a significant clinical importance; hospitalization, is adverse drug reactions (ADRs) ,3; howevThe aim of this systematic review was to investigate whether an assessment of clinical significance can be related to specific DRPs and hence may assist in prioritising individual categories of DRP categorization systems.When conducting our literature search, we sought to identify studies where drug-related problems (DRPs) were identified and categorised, and the clinical significance of the DRPs was assessed. A literature search was performed using the search phrases: A: “drug related problem”, “medicine related problem” and “medication related problem” combined with B: “clinical significance”, “clinical relevance” and “clinical importance” combined with C: “categorisation”, “categorization” and “classification”.described primary researchwere published in Englishdescribed interventions delivered by clinical pharmacistsPublications were included if they:were not published as a research paper did not present data on DRPsdescribed selected DRPs only did not present a DRP-categorization systemdid not present data on an assessment of clinical significancepresented data for a sub-study, where the original study had been includedPublications were excluded if they:The search was performed for the period from 1990 to 2013 using Google Scholar (TRHN). Google Scholar was used to ensure inclusion of the largest possible number of papers, because several studies presenting DRPs were expected to have been published in non-indexed journals. A similar search in PubMed yielded less than five hits.All titles and publication types from the original search were reviewed independently by TRHN and LJK. Subsequently, the abstracts were reviewed by these two authors. Thereafter, full-text articles were reviewed independently by CO and LJK. Finally, CO and LJK extracted data from the studies independently. At every step, disagreements were resolved by consensus. The data extracted were details regarding the study, the intervention, DRP-categorisation, and the clinical significance assessment. Action on DRPs were differentiated between the acceptance rate and implementation rate, because the implementation of a suggested intervention is often dependent on an action by the physician, and even though a physician accepts a suggested intervention, the action of implementing it may be lacking. The clinical significance of DRPs related to medication reconciliation was excluded, since DRPs related to medication reconciliation were not part of the inclusion criteria.n = 8) [n = 8) [n = 5) [n = 7) [A total of 189 studies were identified in the Google Scholar search . After rn = 8) ,17,18,19 [n = 8) ,25,26,27 [n = 5) ,30,31,32 [n = 7) ,37,38,39 [n = 7) ,64,65,66n = 17), followed by community pharmacies (n = 5) (n = 20)  . A singl (n = 5) . Most of (n = 5) . The des(n = 20) .n = 5). Overall, the number of categories used varied considerably among the studies, ranging from six to 17 categories. No category was used by all DRP categorization systems, but some of the categories were frequently used, e.g., “Untreated indication”, “Improper drug selection”, and “Adverse drug reaction”  and DOCUMENT (n = 3); however, 10 studies did not provide any reference to the system used (n = 8); however, some studies did not describe the assessment process (n = 5). The assessment of DRPs suggested that interventions in the included studies were most frequently categorised as “Moderate significant”, followed by “Minor” and “Major”   also useDespite the difference in the categorization systems used for DRP categorization, as well as for clinical significance categorisations, it seemed like the category “ADR” and possibly “Drug interaction” were often associated with a high clinical significance (based on six heterogeneous studies). These two categories were infrequently identified in the studies, but when identified as a DRP, they seemed to be assessed as serious for the patient. No obvious pattern between the remaining DRP categories and the level of clinical significance could be established.An evaluation of the studies, which compared clinical significance of individual DRP categories, showed no apparent relations between the DRP categories and the level of clinical significance in general. However, “ADR”, which was one of the two categories possibly associated with a high clinical significance, has been established as a cause of hospitalization, which does support the relation with a high clinical significance .Additionally, a large difference in the rating of clinical significance within individual DRP categories was observed. This may be explained by the difference in DRPs allocated to individual categories. For example, a high dose of a drug with a narrow therapeutic index may result in considerable damage to the patient compared to the prescription of a high dose of penicillin. Consequently, applying the clinical significance to individual DRP categories does not seem to provide valuable information for evaluation purposes.Despite a great variation in the type and number of categories of the DRP categorization systems, several papers referred to Hepler and Strand  regardinMost authors did not describe the method used to categorise DRPs. Van Mill et al.  reportedNo single category recurred in all of the DRP categorization systems; however, some were frequently used, including the category “Other”, irrespective of the number of other categories. It is possible that this category is merely a “safe guard” to ensure that even rare and odd DRPs have a categorisation option.The large variance in the number of categories available may be due to the type and purpose of the studies and practices locally, such as the need for the level of details, focus of medication review, patient involvement, etc. It is also possible that further categories will be added over time according to the development of medication reviews and appearance of new DRPs, e.g., related to computerised order entry systems ,81. ObjeFinally, the clinical significance of using DRP categorization systems could be considered. For study evaluation purposes, DRP-categorisation systems are often considered as process measures to document a part of the activities delivered by the clinical pharmacist. DRP categorisation seems to be easy to apply in practice, but possibly quite time consuming. Since the ratings of clinical significance within individual DRP categories are inconsistent, the only value of applying a DRP categorization system seems to be of descriptive character. Whether the effort is worth the value should be considered for each individual study.Irrespective of the number of categories available for the clinical significance categorization systems, the vast majority of the DRPs or suggested interventions were allocated into one of the following categories: “Minor”, “Moderate”, and “Major” (or similar). Whether a categorization system consisting of these three categories is optimal, will depend on the purpose of the study. Even though only a few DRPs or suggested interventions end up in the “Extremely important” and “Adverse significant” groups, these categories may serve as valuable sources for intervention purposes, i.e., to improve practice for physicians and clinical pharmacists, respectively. Some systems use a category of “No significance” ,11, whilThe methods used to assess clinical significance included a consensus methodology. For example, expert panels may be a valid method to assess clinical significance, but using this methodology did not identify any obvious pattern between the assessments and DRP categorisation. When a consensus methodology was not used, the correlation between the raters was often low, even though only a few categories were available. This suggests that clinical significance may be related to the instruction of how to use the categorization system, but also the experience, background, and setting of the individual health professional rater. Clinical significance may even be rated differently according to the patient, who is the core person related to the medication treatment. For example, a patient might want to avoid a treatment due to side effects, irrespective of the benefits of the treatment. In addition, variation may also be a result of the variation of the type of intervention, patient population, setting, etc., of the included studies. Hence, using clinical significance categorization systems as assessment methods does not seem robust and is most likely highly dependent on the choice of individual raters. This is supported by a review by Vo et al., who found limited results for the validity and reliability of tools for assessing the potential significance of pharmacist interventions . ConsequGeneralisability may be questioned, since most studies were conducted at selected wards at one hospital and included less than 200 patients. However, the variation in the results of the number and types of DRPs and level of clinical significance may be explained by the heterogeneity of the studies, such as the type of intervention, training of clinical pharmacists, patient population, access to data sources, acceptance rates, etc.Our literature search was challenged by the inconsistency of terminology used within the area of DRPs .” Drug rAs a part of presenting the data, categories were merged from the various DRP categorization systems, as well as for the clinical significance categorization systems. It is possible that the merged categories did not fully correlate with each other.The current review could not establish a consistent relation between the DRP categories and the level of clinical significance. However, the categories “ADR” and possibly “Drug interaction” were often associated with a high clinical significance, albeit they were infrequently identified in the studies (based on six heterogeneous studies). Additionally, an assessment of clinical significance seemed to be a method of low validity. Hence, clinical significance ratings do not seem to be useful in prioritizing individual DRPs of the DRP categorization systems. Indeed, the value of applying DRP categorization systems to evaluate a study should be considered carefully in relation to the time spent performing the categorization. Consequently, it may be necessary to reconsider our current approach for evaluating DRPs.


Microbial biotechnology is essential for the development of circular economy in wastewater treatment by integrating energy production and resource recovery into the production of clean water. A comprehensive knowledge about identity, physiology, ecology, and population dynamics of process‐critical microorganisms will improve process stability, reduce CO2 footprints, optimize recovery and bioenergy production, and help finding new approaches and solutions. Examples of research needs and perspectives are provided, demonstrating the great importance of microbial biotechnology. Wastewater treatment is becoming part of the circular sustainability movement by integrating energy production and resource recovery into the production of clean water. Microbial biotechnology is essential to this development given microbial communities can carry out key processes and combine these in different ways, i.e. removal or reuse of carbon (C), nitrogen (N), phosphorus (P), and micropollutants, and production of bioenergy and high‐value products. The future challenges are to optimize existing systems, e.g. minimize the footprint, reduce the requirement for chemical addition, lower energy inputs, improve process stability, to optimize recovery and bioenergy production and to find new approaches and solutions. This will help to reach the sustainable development goal 6: ‘Ensure availability and sustainable management of water and sanitation for all’ and, to some extent, also goal 7: ‘Ensure access to affordable, reliable, sustainable, and modern energy for all’.et al., et al., Introduction of the circular economy approach in wastewater treatment is already being initiated in some countries  that make up the majority of the biomass and are commonly present across many plants and in many countries  for P recovery through struvite formation or via sludge distribution to the farmland, a better understanding of this process is needed. Several microbes involved in EBPR are now described, but it is still uncertain which species are important in full‐scale plants  process, in which methane is oxidized anaerobically (Raghoebarsing et al., et al., et al., Finding alternatives for biogas production that will yield higher levels in the value chain is also a priority. Production of biogas is presently the method of choice at many WWTPs, but the increased need for various biochemical or other high‐value products, such as biohydrogen production (Kleerebezem and van Loosdrecht, et al., The recent development in DNA sequencing technologies, meta‐omics and other methods provides exciting new possibilities. Within a few years, it will be possible to obtain complete genomes of all important microbes in the systems, including eukaryotes and learn about their physiology and ecology, leading to the next level of ecosystem understanding (Raes and Bork, In conclusion, wastewater treatment is becoming part of the circular sustainability development and integrates energy production and resource recovery into the production of clean water. Microbial biotechnology is, along with other technologies, essential in this development with exciting perspectives in optimization existing systems and development of new.None declared.


I appreciate the opportunity to respond to Dr. Frank's letter  about myNo Harm Studies: 74, or Fewer than 10? Frank characterizes my findings as an “outlier” from 74 studies collected on his website showing no disadvantage for children of gay or lesbian parents. But there are many other studies he did not select, which report difficulties in same-sex partnerships similar to my study. I cited three such studies concerning health difficulties and intimate partner violence (IPV). Messinger's conclusion, for example, is very similar to mine: “concerns over ‘airing the dirty laundry' of an already stigmatized community alongside researcher prejudice or indifference cannot justify treating GLB  IPV victims as invisible, leaving them without support in a painful and potentially dangerous environment.” [onment.”  My study do show disadvantage for children of gay or lesbian parents. Three of these studies employ three separate large population samples, finding similar levels of disadvantage [Frank also does not mention that his website also includes four studies thatdvantage –6. By codvantage , 7 worthdvantage . Asking The Problem of Special Pleading. The validity of Frank's critique is undermined by selective application, known as special pleading. Regarding the sample, my study notes that “same-sex parents were identified using the procedure described by Wainright et al.” [ et al.”  Wainrigh et al.” –11. My sSince Wainright reported benign outcomes from Add Health  12 years ago, Frank has not, to my knowledge, ever critiqued her methods. He features her studies on his website as evidence of no disadvantages for same-sex parented children. Yet when I report adverse outcomes using the same data, sample methods, and a subset of the same sample, he says he is “appalled.” When Wainright refers to the adults in her sample as “same-sex parents”  and their children as “raised by same-sex parents,” Frank makes no criticism. When I use the same language for some of the same cases, he critiques it as “inaccurate.” One of these two responses must be wrong. If Wainright's study was valid and credible when it reported no differences, why is it a flawed study when I, using the same evidence and method, report differences? Every one of Frank's criticisms of my sampling methods applies to Wainright's, so if it is untenable and misleading for me to report adverse outcomes by these methods, it is equally untenable and misleading for Wainright to report benign outcomes.Errors in Criticism. In fact, both my own and Wainright's conclusions are well founded and Frank makes numerous errors in his criticisms. Examine the central statements to support his claim that my description of the children as “raised by” same-sex parents is “wholly untenable”:“All he knows about his dataset is that his subjects, who ranged in age from 12 to 18, spent some of their teenage years with a parent who at some point had a same-sex partner.”“Since we don't know if that partner was ever actually a parent, legally or otherwise, it is inaccurate to characterize such households as ‘same-sex parented' …”That is not true. Following Wainright, I selected “families in which parents reported being in a marriage or marriage-like relationship with a person of the same sex”;  thus the by the children in their care as a parent, as their “mother,” “step-mother,” “father,” “step-father,” or similar. Unlike my study, Wainright did not consult this variable to confirm partner parentage, so Frank's criticism may apply to her sample.“It is even more inaccurate to claim that those living in these households were ‘raised by' same-sex parents, since we know nothing about the youths' parentage before their teenage years.”Again, that is not true. In addition to asking parents about their partners, Add Health asked children about their relationship with all the adults they lived with. The partner parents in my sample were thus all designatedAgain that is untrue, though Frank raises an important point related to family stability. We know a lot about the youth's parentage before their teenage years from these data. At Wave I, Add Health obtained good measures of adolescents' tenure with (length of time in the care of) each parent, with additional retrospective questions on childhood family conditions at Wave III. On the broadest measure of tenure, that is, time in the care of the longer-tenured parent, average parental tenure was close to current age and did not differ between same-sex and opposite-sex parent families.  There are good grounds to say the children were “raised by” these parents.Neither I nor Wainright reported the results for the tenure variable, which was not used in our studies, but in response to Frank's criticism I do now in  higher with longer tenure.  [ understate, negative child outcomes with same-sex parents.The table also addresses Frank's concern that not accounting for shorter stability may overstate child disadvantages with same-sex parents. The time children have been in the care of both current parents is indeed much shorter with same-sex than opposite-sex parents, but the effect of this difference is not what Frank speculates. The table compares age-adjusted odds ratios by family type, by length of tenure with both current parents, for the three primary affective outcomes I examined. Both-parent tenure (ranging from 0 to 20 years) is grouped into four five-year categories; the reference category is five years or fewer. For children with opposite-sex parents, longer tenure with the current parents is associated with lower odds of depression, anxiety, and thoughts of suicide; but the evidence does not support a similar conclusion for same-sex parents, as Frank assumes. For children with same-sex parents, odds of suicide ideation are unchanged by both-parent tenure and odds of depression and anxiety are, if anything,esults.)  Thus, coI think I have addressed enough errors in Frank's critique to establish that his criticisms of my study are unfounded and that my findings are well justified. However, I doubt this will be convincing to him or those sharing his perspective, because what appears to disturb them is not the study methods but the findings. I suspect no evidence will convince Frank that children with same-sex parents may face unique and heightened struggles and difficulties. It is right to be appalled at that thought, but the most useful response is to try to understand the problem better, so as to address the conditions or provide support necessary to ameliorate the problem, not deny the evidence.