An essential element of goal-directed decision-making in social contexts is that agents' actions may be mutually interdependent. However, the most well-developed approaches to such strategic interactions, based on the Nash equilibrium concept in game theory, are sometimes too broad and at other times ‘overlook’ good solutions to fundamental social dilemmas and coordination problems. The authors propose a new theory of social decision-making—virtual bargaining—in which individuals decide among a set of moves on the basis of what they would agree to do if they could openly bargain. The core principles of a formal account are outlined (vis-à-vis the notions of ‘feasible agreement’ and explicit negotiation) and further illustrated with the introduction of a new game, dubbed the ‘Boobytrap game’ . In the first empirical data of how individuals play the Boobytrap game, participants' experimental choices accord well with a virtual bargaining perspective, but do not match predictions from a standard Nash account. Alternative frameworks are discussed, with specific empirical tests between these and virtual bargaining identified as future research directions. Lastly, it is proposed that virtual bargaining underpins a vast range of human activities, from social decision-making to joint action and communication. Where this is so, it appears that, to determine whether any particular action will successfully achieve an agent's goals depends on inferring what the other agents will do. Yet a moment's reflection reveals that inferring the likely actions of other agents appears problematic. Any of the agents may reasonably wonder: ‘How can the other agents possibly infer what I'm going to do, when I don't yet know myself?’ There seems to be the danger that each agent may be ‘lost in thought’ forever, attempting to puzzle out what the others will do.One way out of this puzzle is to abandon the attempt to think in terms of goals at all. So, for example, it is widely assumed that many aspects of group behaviour in animals emerge from the application of algorithmic rules, partially determining the action of a given animal, based on the actions of nearby animals. For instance, a variety of models of flocking show that a coherently moving flock may emerge from very simple local rules for adjusting the flight of each bird in the light of the movements of neighbouring birds –3; and mBut if our focus is the theory of goal-directed behaviour, then a different approach is required. We need to face, squarely, the question of how several agents may attempt to pursue their own goals, in the knowledge that the consequences of their actions may be mutually interdependent. By far the most well-developed approach to this problem stems from the notion of Nash equilibrium and best-reply reasoning, developed in game theory.a) game, there is just one Nash equilibrium of  in which both players ‘Defect’, even though it would be better for both players to attain  by playing ‘Cooperate’. Mutual cooperation  is not a Nash equilibrium because either player can unilaterally switch from C to D and gain an improved pay-off (3 rather than 2). But  is a Nash equilibrium, because neither player can unilaterally improve their pay-off by switching .In a Nash equilibrium, each agent makes a ‘best response’ to the action of the other agent—where ‘best’ is determined entirely by the agents' own pay-offs. For example, in a social interaction with the structure of the canonical Prisoner's Dilemma PD; a game, tb). Each player must choose between Heads and Tails. One player wins if both choose identically; the other player wins if both choose differently from each other. No set of deterministic choices constitute a Nash equilibrium in this game, because the losing player is clearly not responding best to the other's move; indeed, the losing player can unilaterally switch to become the winner by changing their response. But Matching Pennies does have a mixed strategy Nash equilibrium: each player chooses Heads and Tails with 50% probability, literally by spinning a coin.So far we have considered ‘pure’ Nash equilibria, but many games also have ‘mixed strategy’ equilibria, where one or more players choose their actions probabilistically, rather than deterministically. For example, consider the Matching Pennies game b. Each pc) in which, unlike PD or Matching Pennies, the players' interests align, rather than conflict. Here, there are two ‘pure strategy’ equilibria of  and  .Nash ,7 famousfigure 1selecting one equilibrium among others. The notion of a Nash equilibrium needs to be ‘refined’, to pick out one such equilibrium over the others.In social interactions that can be modelled as a game with multiple equilibria, producing predictions about what players should choose requires actually send such messages—it is in this sense that the bargaining is ‘virtual’). To provide some initial motivation for this approach, consider another coordination game, Hi–Lo , where e). That is, imagine players who have to bargain concerning whether they should choose an option which has mutually good pay-offs (9 and 10 units) or one which has very asymmetrical pay-offs (12 and 1 units). Both players know that it is very unlikely they would mutually agree to choose the second, as the disadvantaged player will never concur. Thus, according to virtual bargaining, both players in this Battle-of-the-Sexes game will know that this is true, know that the other knows it, etc.; and hence both will spontaneously choose A, not B, alighting on the  equilibrium.We will consider how this can be modelled more formally below. But for now, let us provide some intuitions favouring the virtual bargaining approach. In particular, note that the account presumes that factors that would influence actual bargaining will tend to influence the virtual bargaining, which might involve the ‘mental simulation’ of an actual bargaining process. In real bargaining, for example, consider how one would react when faced with the two pure strategy equilibria in the ‘Battle-of-the-Sexes’ game e. That if, which provides an example where the summed pay-offs are so unfairly divided that they would not be agreed by real bargainers. The virtual bargaining account accordingly predicts that this equilibrium would not be selected.So far, one might wonder whether, rather than engaging in bargaining, both players are simply choosing the equilibrium of the greatest summed pay-offs. For example, rather than seeing the players as bargaining to achieve a solution, we might consider the players to reason instead as part of a ‘team’ whose objective is to maximize the total pay-off to the team members see ,9). Howe. Howe9])figure 1same item , then this may be a particularly natural suggestion for the ‘virtual agreement’ equilibrium [The virtual bargaining account, as developed here, makes predictions based on the ‘goodness’ of virtual bargains, not how such bargains are arrived at. Thus, it is a type of equilibrium explanation, in the tradition of the Nash equilibrium and its refinements. But understanding the psychological processes that lead to a particular virtual bargaining outcome remains an important challenge. Indeed, a process-model may turn out to have important implications for the equilibria attained. For example, in games where people are rewarded when they independently choose the  colour; ,11), comilibrium . Thus, c2.Thus far, it has appeared that the notion of a Nash equilibria is too broad. Interesting social interactions often have multiple Nash equilibria and require additional constraints for selecting one equilibrium above the others. Virtual bargaining provides one way to do this, among many others , and which we will explore experimentally below. The Boobytrap game is a modification of PD, in which an additional ‘move’ is added: the ‘boobytrap’. If a player chooses Boobytrap (B), their pay-offs will be precisely the same as if they had chosen Cooperate (C), except for a small reduction in each pay-off that can be conceptualized as the cost of ‘buying’ the boobytrap. Moreover, playing B is the same as playing C with respect to its effect on the other player's outcomes, with one crucial exception: if the other player chooses Defect (D), then that player receives a steep negative pay-off.We illustrate this type of case by introducing a new game, which we call the ‘Boobytrap game’ shown in a, and whThe Boobytrap game has just one Nash equilibrium of . The cost of ‘buying’ the boobytrap means that B yields a slightly lower pay-off than C, regardless of the action of the other player. Therefore, no pair of strategies involving B from either player can possibly be a Nash equilibrium, because switching from B to C will always be a better response to the other's move—whatever that move might be. By this logic, the players can infer that neither of them will choose B; and hence the game collapses back into a standard PD game, with the usual suboptimal  equilibrium.unenforceable. Assuming no altruism or similar, each player knows that, if they go through with their side of the bargain, the co-player may exploit them by Defecting—that is, the other player will be able to profit at their expense. But no such exploitation is possible for . Each player knows that if they go through with their side of the bargain, playing B, then no exploitation is possible; if the other plays D, then this will be mutually damaging. If the other plays B or C, then the first player obtains a good pay-off in either case.But there is a better ‘bargain’ to be had: . Consider, for a moment, that the players can bargain face-to-face. They can immediately see that  is a better outcome than . Now  is better still, but the problem is that it is So, there is a possible, non-exploitable bargain that has better pay-offs for both players than the Nash equilibrium. By playing B, a player deters the other from playing D. And hence the social interaction works to the benefit of both players. As both players know that this bargain is mutually advantageous, they can play it without having to explicitly bargain.Here, then, the virtual bargaining account diverges sharply from most accounts which assume the Nash equilibrium as a starting point; in this game, a good virtual bargaining solution may not be a Nash equilibrium at all. We shall examine how people actually play the Boobytrap game presently.The possibility of virtual bargaining between antagonists marks the division between the virtual bargaining account and an important set of related ideas developing the notion of ‘team-reasoning’  and the 3.feasible agreement picks out a set of possible ‘virtual bargains’, from which the players choose. The second step is the claim that, except in unusual circumstances which we shall not consider here, virtual bargaining is governed by the same principles that govern explicit negotiation.The theory of virtual bargaining can be made precise in a number of different ways. Here, we provide a sketch of the structure of such a theory, leaving technical developments and alternative analyses for future research. There are two core ideas. First, the notion of a feasible, if neither player can exploit the other to their own advantage. That is, given the strategy of the other, neither player can, by varying their strategy, gain advantage for themselves, to the disadvantage of the other.(i) A pair of strategies  is The rudiments of a formal account can be encapsulated as follows, for the case where there are two agents. in any way at all; this immediately implies, of course, that neither player can unilaterally change their strategy to exploit the other .Note that the set of feasible strategies is weaker than, and contains all, Nash equilibria. At a Nash equilibrium, neither player can unilaterally change their strategy to their own advantage (ii) The goodness of a feasible bargain is, following Nash's theory of bargaining, the product of the utility gains to each player (relative to a no-agreement baseline) of adhering to that agreement .How can the ‘goodness’ of a bargain be evaluated? In the absence of a well-developed formal theory of explicit negotiation (and perhaps with the expectation that such theory may not be possible), we should similarly not expect a complete formal theory of virtual bargaining. Nonetheless, we shall see that existing formal accounts of explicit bargaining, such as Nash's theory of bargaining , while iare feasible, including the pure strategies ,  and, of course, the Nash equilibrium .Let us illustrate these steps by considering PD and then its modification, the Boobytrap game. For conventional PD, consider cases in which both players agree to adopt strategies with a non-zero probability of C. Then each player can exploit the other by not going through with their side of the bargain, but by playing D with probability 1. So no such pairs of strategies are ‘feasible’. Conversely, all strategies in which one player plays D with probability 1 negative expected pay-off for the second player compared with the ‘baseline’ of also playing D. So the product of utility gains of the pair of players for any such bargain will be negative. The bargain  will have a 0 gain over this default option  is the default option for each player). So the ‘best’ feasible option is . So bargaining does not lead to an improved outcome: the theory of virtual bargaining does not, directly at least, help explain why people so frequently cooperate in one-shot PD.Note that, by choosing D, each player can guarantee a pay-off of 20 units. But any bargain in which one player chooses D, but the other has a non-zero probability of playing C, will have a a, the pay-offs are . Can bargaining lead to a better outcome? It turns out that this is possible. Suppose each player ‘buys’ a Boobytrap for certain. The pay-offs are now , and this is a feasible bargain, as neither player can exploit the other. To be sure, if one player knows that the other will play Boobytrap, then the first player can simply cooperate, thereby saving the ‘cost’ of the Boobytrap . But this leads to no disbenefit to the other player, who obtains pay-off 29 nonetheless. So  is a feasible bargain , and it is a better bargain for both players than that achieved by the Nash equilibrium.Now let us consider the Boobytrap game. The game also has a single  equilibrium, which we shall take as the default outcome, where no bargaining occurs. In the specific Boobytrap game in figure 2p − 100(1 − p), where p is the probability of playing C) is less than from playing C (i.e. 30), so that there is no incentive to play D. Simple algebra reveals that this holds when p < 13/14, and hence the probability of playing B is at least 1/14. Under this solution, expected pay-offs for each player are very nearly 30, and far better than the  pay-offs obtained in the Nash equilibrium.Indeed, the players can do even better. They just need to buy the Boobytrap sufficiently often that the other player has no incentive to Defect. It turns out that the best possible bargain for each player in the specific boobytrap game we are considering is achieved when each player plays B with probability  1/14; and otherwise plays C. This figure is obtained simply by considering the fraction of Bs required of a B/C mixture such that the co-player's pay-off by playing D M = 21.4, s.d. = 2.1) were recruited from the University of Warwick through an online participant recruitment panel. Participants were paid £5, in addition to any earnings  determined proportionally from their pay-offs in one randomly selected game.Eighteen undergraduate and postgraduate students ,  and  equilibria) over games, whereas Nash equilibrium theory predicts the ‘CD’ outcome  or  equilibria; see also discussion below). Therefore, these ‘reduced’ versions of the Boobytrap game capture relevant dimensions of interest in the full Boobytrap version, while also making contrasting predictions from Nash and virtual bargaining perspectives.The specific pay-off values from the Boobytrap game matrix in figure 2z-Tree (Zurich Toolbox for Readymade Economic Experiments) software [Using the software  to preseRow gets 40’, ‘Column gets 10’). To control for position effects, the locations of strategies in the 2 × 2s were randomized and counterbalanced for each subject, so that on any given trial, each subject saw a different configuration of the same matrix. To avoid label effects, participants did not see strategy labels  for any matrices, but instead clicked on unlabelled buttons alongside each column or row to indicate their selection. Participants made their choice without knowledge of the other player's decision and received feedback on their screen regarding the outcome of their joint decision after each game.The four 2 × 2 matrices were each presented 20 times, in random order, for a total of 80 games. This was then followed by 10 presentations of the full 3 × 3 matrix. To make the pay-offs easier to read, some minimal text was added within cells (e.g. ‘(b)The mean rates for choosing the various strategies per game were calculated for each participant and then averaged to obtain the group means displayed in . Because C should clearly be the preferred choice in this context, participants’ selections provide a basic check that they understood how to interpret the abstract matrices. For Matrix 2, participants chose the Defect, over Cooperate, strategy a vast majority of the time (92.5%); thus, without the Boobytrap strategy, the baseline rate of defection for the standard PD game is very high. For the reduced versions of the Boobytrap game in Matrix 3 and 4, this preference reverses; when deciding between C or D in the context of the other's C or B, participants chose Cooperate 86.1% of times. Further, when deciding between C or B in the context of the other's C or D, participants chose Boobytrap about a third of the time .As displayed in t17 = 2.79, p = 0.01); but the mean rate of boobytrapping does not differ (p = 0.21). There are no significant changes evidenced for the other game matrices, including the full 3 × 3 Boobytrap game. Thus, even with the change noted above, performances in boobytrap games do not conform to standard Nash predictions throughout (more on this below). Importantly, for the boobytrap matrices, defection is low and boobytrapping is present from the onset . As none of the individual choice patterns in this section change when considering experimental halves separately, we report subsequent analyses across the whole of the experiment.To check whether potential learning during the experiment may have influenced results, we recomputed the means displayed in ps > 0.05. This resulted in similar group frequencies to the reduced versions  and indicates that neither the mere availability of a third option as such, nor the added complexity of the matrix in 3 × 3 form are principally driving participants’ results. Yet, there was a significant difference in defection across Boobytrap games (reduced and full versions) and PD games in F2,34 = 199.59, p < 0.001), with planned comparisons revealing a dramatic reduction in the proportion of defection from PD to that in the reduced Boobytrap game (when constrained to choices C and D), CI95 = 0.66 to 0.92, p < .001, and from PD to the full Boobytrap game, CI95 = 0.70 to 0.98, p < 0.001.Accordingly, the overall distribution of choices in the full, symmetric version of the Boobytrap game (Matrix 5) also shows a high proportion of Cooperate and Boobytrap strategies relative to Defect: 69.4% C, 21.7% B and 8.9% D. Individuals' selection rates for each of these strategies did not differ from their rates for the strategies' counterparts in the reduced Boobytrap games shown in Following §3, virtual bargaining predicts a mixed strategy of ‘cooperative’ choices (C and B) in which B is played sufficiently frequent so as to deter the other player from D. For example, consider Matrix 3. Row should only need to play the Boobytrap strategy with some probability infinitesimally above 1/14 to rationally deter the Column player from Defect. As boobytrapping increases above this frequency, the expected utility to the Column player from choosing D decreases and defection becomes increasingly disadvantageous. The same holds true for Matrix 4, but with roles reversed. And indeed, in our experimental Boobytrap games, participants did choose B at rates well above the threshold of ≈7%. Strategy D was correspondingly chosen the least often, at rates representing more than a 75% decline from those in the standard PD game.CD outcome in the reduced boobytrap matrices; C dominates B for the player with these available strategies (i.e. C provides better pay-offs to B irrespective of what the other player chooses), whereas the other player's best reply to their opponent's expected C is D. So when constrained between C and B, a standard Nash account predicts that one always chooses a pure strategy of C; when constrained between D and C, a Nash account predicts that D should always be chosen. However, this is not observed in participants’ choices from t17 = 4.41, p < 0.001). And when deciding D or C, participants chose C significantly more than D , in direct contrast to the Nash equilibrium prediction.Alternatively, Nash equilibrium theory predicts the 5.We have focused on the contrast between our virtual bargaining account of the Boobytrap game and the standard Nash equilibrium in the game: . But there are, of course, many other models in game theory that might be applied to the Boobytrap game.One approach is to enrich the agent's utility functions to include ‘social preferences’  by assumoutcomes received by each player that matter, then the process by which those outcomes are achieved should not be important. If the first player sufficiently prefers the  outcome to the  outcome , then that player will choose B rather than C.If this is correct , then the decision to choose the Boobytrap can also be maintained if the choice of the other player is randomly determined. Specifically, suppose that in the full 3 × 3 Boobytrap game, the co-player's move is determined by flipping a coin, such that the co-player chooses C or D with probability 1/2 and is constrained to not play B. If it is the By comparison, though, completely different results are expected from a virtual bargaining viewpoint. A player cannot form a virtual bargain with a second player whose behaviour is being determined by a random device, as the second player is in no position to implement any virtual agreement. Hence, other things being equal, the virtual bargaining account would predict that the frequency of the non-random player deciding to choose B would be substantially reduced under these circumstances. This contrast in predictions thus provides the basis for a strong empirical test between the present virtual bargaining account and accounts based purely on outcomes, which awaits future experimental work.best response (i.e. the response yielding the maximum expected utility), given the probability distribution over the other's moves. Rather, players are more likely to choose a response to the extent that it has a high expected utility. Depending on a free parameter, which determines the noisiness of responding, QRE's predictions range from completely random responding (with each response having a probability of one-third for both players) to collapsing back to the Nash equilibrium as the level of decision noise tends to zero.A second alternative way to explain the choice of B in the Boobytrap game is as a result of ‘noise’ in the choice process. For example, a popular generalization standard Nash equilibrium is so-called Quantal Response Equilibrium (QRE ), accordThus, with sufficient noise, QRE can predict B is played fairly frequently—and where it is played frequently enough to successfully deter D, then D will be suppressed, as observed in our experiment. Note, though, that QRE makes the very strong prediction that the frequency of C responses must always be greater than the frequency of B responses. This is because C has a higher pay-off than B whatever the other player does; that is, C dominates B, and frequencies are positive monotonic functions of expected pay-off.Now consider the Boobytrap game in By contrast, QRE predicts a very different pattern. Because B is constrained to be less frequently chosen than C, it cannot be chosen sufficiently often to be an adequate ‘deterrent’ to the choice of D. So D will be the most frequent choice, followed by C, and finally B. Exploring what happens when the boobytrap is less ‘potent’ is thus a critical test between QRE (and noise-based models more broadly) and the virtual bargaining account, and the natural topic for future experimental work.6.In humans, whether we achieve our goals often depends not only on our own actions, but on the actions of others. In such cases, successful goal-directed behaviour often requires two or more people to coordinate their actions successfully, whether in passing each other in the corridor without collision, playing a duet or a game of football, collaborating on a research project or a business venture, or dividing up and carrying out tasks within a family unit. The theory of virtual bargaining aims to provide the starting point for an account of how this is possible.We have considered virtual bargaining in cases where the goals of the players may be diametrically opposed . But virtual bargaining is also applicable in contexts where players have common goals, but the challenge is to infer how to coordinate their behaviour to achieve those goals. Arguably, such problems of coordination are central to a vast range of human activities, in which people must jointly attend to the same information, jointly plan how to react to that information and jointly engage in appropriate actions—as exemplified in a range of activities including conversation, collaborative musical or theatrical performance, many types of improvised dance and collaborative projects from putting up a tent to writing an academic paper.As noted earlier, a particularly simple example of such coordination games is the Hi–Lo game, in which players must independently choose to respond H (‘Hi’) or L (‘Lo’). Recall that if the players choose different options, neither obtains any reward. However, if the players both choose Hi, they both receive a large prize, and conversely, if they both choose Lo, they both receive a small prize. Experiments consistently show, as intuition would expect, that Hi–Hi is overwhelmingly chosen .A full evaluation of the virtual bargaining theory would, of course, require a much broader review of the experimental literature on games, and this would go far beyond the scope of this paper. We note, though, that the scope of the present account is quite broad. Consider, for example, the Ultimatum Game. In one version, Player 1 announces a ‘split’ of, say, $100; Player 2 announces a ‘minimum’ sum to which they will agree. If Player 1's split is less than Player 2's minimum, neither player gets anything. Otherwise, the players receive the split as suggested by Player 1. Under fairly natural symmetry assumptions, the best bargain (judged by Nash bargaining) will be a 50–50 split; and virtual bargaining then suggests that this bargain will be implicitly ‘agreed’ by the players. Indeed, the 50–50 split is the modal outcome in many experiments. This provides an alternative, or perhaps complement, to standard economic accounts based on fairness . A naturIt is natural to view communication itself as a coordination game of the type above, but where both sender and receiver of a communicative ‘signal’ must coordinate on the same interpretation of that signal, within the space of a vast number of possible interpretations. Facial expressions, gestures and utterances all, notoriously, hugely underspecify the content that is to be communicated. Only by extremely complicated processes of ‘pragmatic enrichment’ is it possible to interpret a raised eyebrow as, perhaps, expressing the implausibility of a specific philosophical position, or to interpret a brief shudder as a request to close a draughty window . Communisame interpretation as each other. This contrasts with animal signalling such as ‘stotting’ where a gazelle's jumps in the presence of lions may signal its fitness [pointing to a defender only gives information about the likely pass if the point is interpreted by the defender as communicative , rather than, say, as a random wave of the arm. Empirically clarifying the boundary between cases where signal is sent intentionally, which can be very intricate [common knowledge of the intention of the signal is an important topic for future work. The present approach can be viewed as a step towards providing a formal underpinning for the theory of psychological communication developed by Clark and co-authors [Note that, in the current framework, communication requires common knowledge that the action to be interpreted is communicative: both sender and receiver aim to infer the  fitness  and hencntricate , and tho-authors ,43,44 an-authors .We see the foundations of understanding human communication as a particularly rich area for the application of the theory of virtual bargaining. Moreover, if we are right, then virtual bargaining underpins the ability to bargain explicitly, using linguistic or other modes of communication; without virtual bargaining, we suggest, communication, and the complex cultural structures built upon it, would not be possible.


Madre de Dios is located in the southeastern Amazonian region of Peru. Rodents have been estimated to be the reservoirs for up to 50 % of emerging zoonotic pathogens, including a host of viruses, bacteria, and parasites. As part of a larger study involving both human and animal research, this study serves to obtain a broader understanding of the key challenges and concerns related to health and rodent-borne illnesses from the perspective of the people living in these communities.n = 522) in four communities along the Inter-Oceanic Highway (IOH) in Madre de Dios, Peru over a two-year period.We used a mixed methods approach, which comprised of 12 focus group discussions, 34 key informant interviews and the application of a survey (Although 90 % of survey respondents answered that rodents can transmit diseases and had seen rodents in their homes and immediate surroundings, most could not name specific rodent-borne diseases and, when probed, described rodents as pests or nuisance animals, but were not concerned about acquiring illnesses from them. Key informant interview data suggests that there has been a perceived increase in the amount of rodents in the communities since the construction of the IOH, however this potential increase was not coupled with increased knowledge about diseases or perceived risks among these key informants. Health providers also mentioned a lack of diagnostic tools specific for rodent-borne illnesses. This may be related to the fact that although a common rodent-borne disease like leptospirosis is frequently detected in the region, it is not routinely and readily diagnosed, therefore the real burden of the disease and exposure risk can be underestimated. If rodent-borne diseases are not on the radar of health professionals, they may not consider presumptive treatment, which could result in unnecessary morbidity and mortality.Awareness of rodent-borne diseases is still lacking in the area, even among health care professionals within the communities, despite the known burden of diseases like leptospirosis. We expect to report further findings as we obtain more information from all the study components. Hantavirus, Arenavirus, Leptospira, and Yersinia pestis, the etiologic agents of hantavirus pulmonary syndrome (HPS), several haemorrhagic fevers, leptospirosis and plague, respectively …. The people do not know of the existence of these diseases.” Less than half of the KIs with non-health related roles had heard of the diseases and, of those who had, bubonic plague was the most commonly recognized. Two KIs  also said, unprompted, that rodents are dangerous because they could spread rabies.In two communities (B and E), none of the KIs thought that rodents were perceived as dangerous, whereas in other communities, KI representing a range of backgrounds, including health, revealed an accepted co-existence with rodents that was not perceived as very dangerous, though there was an acknowledgement that it might be due to lack of knowledge regarding possible diseases they transmit: “Because we don’t know what diseases or what they could do to us.” Or as another KI stated: “I’ve seen that the rodents here are healthy… I’ve seen what they eat: roots, fruit, Brazil nut, but there are few that are in the sewers…” Or, an example of the accepted coexistence: “…I think people are used to them, they don’t even kill them. Maybe people are not very aware [of diseases rodents transmit]”. Another KI from the health field reported that rodents were not a problem in the more “urban” parts of their community, but that people who work in the field harvesting maize get bitten and are at a higher risk: “Right here within the community I have not seen people complaining about rodents, but those who have complained are those who live outside of the town center… those who are outside have come to me because of rodent bites. It affects people who grow corn mainly.”One KI  reported that there had been two cases of leptospirosis within the past year, with two farmers contracting the disease. The disease had been mistaken for dengue or malaria due to similarity in symptoms, and diagnosis had been difficult due to lack of diagnostic tools: “Yes… they have had leptospirosis… two cases last year. Farmers. People thought it was dengue…”. Aside from this information from this KI, there was no information available about incidence of any of the rodent borne diseases in these communities. Most of the KIs did not know about potential cases of rodent-borne diseases and three KIs  in three different communities were sure that there had not been any incidence of rodent-borne diseases.Similar results were found in the survey applied in 2015: more than 80 % of all surveyed households had seen rodents in their house and over 65 % had seen them in their community. When asked if the rodents were considered a pest in the community, more than half (59 %) of the respondents answered yes, 33 % said no and 8 % did not know. Regarding rodent-borne illnesses, 90 % of the respondents from each community thought that rodents could transmit (unspecified) diseases. In accordance with KI and FG findings, survey participants responded that routes of infection for rodent-borne diseases were skin contact with rodent urine or faeces (26 %), contamination of the environment and food (26 %), and rodent bites (20 %). Only 2 % of respondents considered ectoparasites as vectors of infections (referred to as fleas or ticks within the survey). Of the 522 survey respondents, 65 specified that there were “other” routes of infection and 60 of these respondents cited rodent hair as a form of infection transmission.Various rodent eradication methods were mentioned in the FGs, but owning a cat was the most common method. Other rodent control practices mentioned include the use of traps and poisons, such as “Campeón” or “Racumín”. In one FG, some participants mentioned the use of a powder that is placed along paths of the rodents; however, other participants in the same group disagreed with its effectiveness, explaining that rodents ate the powder but did not die from it.KIs in 2014 had similar responses to rodent control as the FG participants, and spoke of their own experiences. Cats were the most effective rodent control practice: “Having a cat works, they guard the house,” explained a KI from a community. However, others described frustration at being unable to eradicate rodents after many efforts, because they urinate in people’s homes: “I’m getting tired of washing my clothes every time. Poison doesn’t kill them, neither do cats.” One KI mentioned that there had been an increased demand for poison for rat control (this was not verified). In 2015 KIs were not prompted for rodent control practices, but approximately a third of the KIs spontaneously mentioned similar strategies as those mentioned in 2014; one KI who also owned a shop on the IOH reported that people shopping for rat poison, and a few KIs mentioned that many people own cats for rodent control.chacra” ), 51 % of respondents reported that they would kill it, 22 % would “shoo it away” and 12 % would ignore it. Regarding reasons why rodents enter people’s homes, participants responded that food was the main reason (88 %), followed by “dirt” (8 %), as well as that rodents were looking for a nest or refuge.Findings from the 2015 survey were similar to those obtained via qualitative methods. To prevent rodents from entering the house, 32 % of respondents said the most effective means was to keep the house tidy, and 31 % stated that keeping a cat prevented rodents from entering. To eradicate rodents, the most common survey answer was to put poison down (47 %), keep a cat (24 %) or set traps (14 %). Other preventative responses included manually rodent-proofing the house (“closing the house”). When asked about reactions to seeing a rodent , the KI interviews from 2014 (whose observations were similar to those of the community) and the KI interviews in 2015. More than half of the KIs interviewed in 2015 reported observing an increase in the number of rodents since the IOH construction, while in 2014 all KIs reported the presence of rodents, but only a few reported increased numbers. The main reason given by the KIs in 2015 for the increase in the number of rodents was the increase in the number of people, as well as more small stores and restaurants in the area: “Now that we are a number of people, there are rodents. Especially where there are restaurant services, that’s where you find them”.In contrast, one of the authors  also reported noting a difference in the amount of rodents collected  in smaller communities like La Novia in contrast to a baseline study conducted in 2009, where the area was considered of high abundance and diversity in rodent populations . The rodent collections performed since 2013 in this site have had very low yield and trap success rate, which may be related to the expansion of agriculture, in-migration and settlement of people in the community, changes that have been evident throughout the study period and will be further analysed in another paper.As part of the research activities, a group of trained field epidemiologists, veterinarians and field workers conducted trapping sessions in six grids within each of the four study communities. Results from the first three trapping periods, conducted in December 2013 and in May and October 2014 are presented in Table O. microtis, E. nitudus and N. lenguarum were the most commonly trapped rodents in these study sites. Additionally, the type of habitat  where these species were most frequently found is in Table O. microtis in their households, which have been found in more abundance than other rodent species throughout the four communities and mainly in edge and disturbed areas.These data show that Hantavirus in N. spinosus, N. lenguarum, E. nitidus and the presence of the virus in two N. spinosus mice [O. microtis (43 %), which has been related before with Hantavirus in the Loreto department in the northern Amazon Basin [O. microtis has been found frequently in edge and disturbed areas, suggesting that the report of finding the rodents within the households may be feasible.Evidence of rodent-borne disease agents has been identified in rodents in the areas surrounding these communities, including antibodies to sus mice . While tsus mice –24, inclon Basin . Our finBased on our qualitative study, rodents were primarily described as a nuisance: they eat their food and can carry fleas and are a very common sight in local households. Residents of small communities along the IOH in Madre de Dios were not familiar with the risk of specific rodent-borne diseases or potential for exposure through their excreta or arthropods. However, exposure to urine or faeces was listed as the most common route of infection by survey respondents and the survey also showed that the communities were very aware that rodents carry diseases.Leptospira . Nonetheless, few participants from our study could name any rodent-borne diseases. This limited knowledge about diseases is understandable considering that even if individuals in these communities have acquired rodent-borne diseases, these are likely misdiagnosed due to the lack of awareness of these diseases and the resource-limited health centers. For example, leptospirosis could easily be misdiagnosed for dengue, malaria or influenza, because of the similarity of the initial symptoms. Therefore, it is likely there are underreported cases of rodent-borne diseases in these communities due to the limited laboratory infrastructure and health care personnel within the communities.Due to the high burden reported in previous studies, it is mandatory to report leptospirosis in the region . RecentlEarly diagnosis or treatment of more common rodent-borne diseases, such as leptospirosis, could reduce morbidity and mortality . SurveilRattus rattus or Mus musculus, and a decrease in the diversity of other rodent species (wild rodents). At any rate, the data collected in the past two years shows a shift in the population composition of the different species of rodents depending on the level of disturbance of the land, probably as more generalist species take over habitat ranges previously used by specialists [et al where Hantavirus prevalence showed an increase in areas with decreased biodiversity [Studies have shown that disturbed habitats are ideal for the emergence of rodent-borne diseases , 28. Thecialists . These civersity .By design, the sample size of the qualitative portion of the study was limited, but adequate for exploring the key themes we were interested in, and saturation in our communities was reached. Future research, both of human and rodent components, should expand to more communities along the IOH, as well as along rivers in the region, to allow for more rich and diverse comparisons, and to examine how rodent diversity and population size compares by type of setting and the varying land use in different communities. However, the results of this study have implications for future research and policy not only in Madre de Dios, but also for other geographically similar regions of the world –37. RodeIn summary, we found that the general population are not aware of rodent-borne diseases and are not concerned about rodents or their presence; they are seen as pests. There are mixed reports regarding changes in rodent population since the construction of the IOH with the most recent KI data suggesting that there has been an increase in rodents in the communities. However, this potential increase has not changed beliefs or attitudes about rodent-borne disease. Moreover, a lack of knowledge about rodent-borne diseases, even among health personnel, still persists in this region.Findings from this project could be used to improve awareness of, and possible diagnosis of, rodent-borne diseases among health professionals in the region, and educating the communities about rodent-borne diseases to improve preventive behaviors. With increased awareness among health professionals and communities, the importance of seeking lab diagnostics for potential rodent-borne diseases is emphasized, reducing severe disease or even mortality associated to these diseases. Health care professionals who are not aware of prevalence of rodent-borne diseases in their region may not consider presumptive treatment for these, which could result in unnecessary morbidity and mortality.FG, focus groups; IOH, Inter-Oceanic Highway; KI, key informant; NAMRU-6, Naval Medical Research Unit No. 6; RD, directorate resolution; SERFOR, Servicio Forestal y de Fauna Silvestre (Peruvian Forestry and Wildlife Service); SERUMS, Servicio Rural y Urbano Marginal de Salud


In their article published in this issue, Van Tongeren-Alers et al.  conducteWe know that certain factors affect students’ career decisions. Chief among these is experience: if students are exposed to a speciality and enjoy it, they are more likely to pursue that career . HoweverRole models are another influence on students’ career decisions, especially during clinical placements . Here, aThe above arguments indicate that social and cultural processes influence career decisions, but can such processes be said to restrict choice? Consideration of discourses may allow deeper exploration of these phenomena. Discourses of masculinity include characteristics of strength, decisiveness, independence, whilst those of femininity include empathy, communication, collaboration . DiscursPoststructuralist feminist critique considers gender not as biological, but as performative —in termsDifferent theoretical stances attribute differing degrees of agency—the capacity for self-direction—to individuals ‘making choices’ in the world. The sociocultural stance we adopt above holds that discursive constraints, such as gender, class, ethnicity and sexuality operate to restrict available options; or, to put it another way, the possibilities that are available are largely determined by an individual’s background—or rather their embodied history-in-person—and the conditions of the society in which they operate . DiscourMore individualistic perspectives differ from a sociocultural stance in that individuals become the ‘locus’ of agency; individuals are free to decide their future, taking into account how they see the world. It is towards this end of the epistemological spectrum that we position the literature on ‘career choice’ in medical education, one of whose features as a field is, what Bleakley terms, the ‘widespread uncritical acceptance of andragogy’ , which sSo, how to proceed? Likely we can all agree on the importance of supporting medical students to navigate the various careers available, and take the best path for themselves. As Van Tongeren-Alers et al. suggest, the method of gender mainstreaming may be useful;  it rendeStudies to identify gender imbalance in medical education are often accompanied by a desire to address the issue. The contemporary social sciences have given us the tools to do so, to move beyond demography and biology in our discussions, in teaching and learning, and in research, and to begin to better address the gender issues that so concern us.


Treatment for multi-drug resistant tuberculosis (MDR-TB) is lengthy, has severe side effects, and raises adherence challenges. In the Médecins Sans Frontières (MSF) and Ministry of Health (MoH) programme in Karakalpakstan, Uzbekistan, a region with a high burden of MDR-TB, patient loss from treatment (LFT) remains high despite adherence support strategies. While certain factors associated with LFT have been identified, there is limited understanding of why some patients are able to adhere to treatment while others are not. We conducted a qualitative study to explore patients’ experiences with MDR-TB treatment, with the aim of providing insight into the barriers and enablers to treatment-taking to inform future strategies of adherence support.n = 35) and health practitioners , including five follow-up interviews. Interview notes, then transcripts, were analysed using coding to identify emerging patterns and themes. Manual analysis drew upon principles of grounded theory with constant comparison of codes and categories within and between cases to actively seek discrepancies and generate concepts from participant accounts. Ethics approval was received from the MoH of the Republic of Uzbekistan Ethics Committee and MSF Ethics Review Board.Participants were purposively selected. Programme data were analysed to enable stratification of patients by adherence category, gender, and age. 52 in-depth interviews were conducted with MDR-TB patients (Several factors influenced adherence. Hope and high quality knowledge supported adherence; autonomy and control enabled optimal engagement with treatment-taking; and perceptions of the body, self, treatment, and disease influenced drug tolerance. As far as we are aware, the influence of patient autonomy and control on MDR-TB treatment-taking has not previously been described. In particular, the autonomy of married women around treatment-taking was potentially undermined through their societal position as daughter-in-law, compromising their ability to adhere to treatment. Patients’ engagement with and adherence to treatment could be hindered by hierarchical practitioner-patient relationships that displaced authority, ownership, and responsibility from the patient.Our findings reinforce the need for an individualised and holistic approach to adherence support with engagement of patients as active participants in their care who feel ownership and responsibility for their treatment. In 2013, approximately 480,000 people globally developed multi-drug resistant tuberculosis (MDR-TB), defined as TB resistant to rifampicin and isoniazid .A meta-analysis of MDR-TB treatment studies across 31 countries found a pooled proportion of patients lost from treatment  of 14.8 %. Strategies associated with reduced LFT include engagement of community health workers in administering and observing treatment, smaller cohort sizes through decentralised care, patient education, and a package of adherence interventions such as nutrition and financial support . It is pUzbekistan is one of the high priority countries for drug-resistant TB in the European region, with 23 % MDR TB amongst new TB cases . In Karan = 1,190), 57 % had a successful treatment outcome, 27 % were LFT, 9 % died, and 7 % failed treatment. Adherence support strategies in the programme include: individual pre-treatment assessment by counsellors to provide information and assess readiness for starting treatment; one-to-one counselling or psychiatric support if needed; engagement of family members and family information sessions (with patient consent); peer support group meetings; and social support. In addition, health practitioners receive training sessions on adherence and communication. However, rates of LFT from MDR-TB treatment remain high.Among patients starting treatment for MDR-TB between 2009 and 2012 . Patients were stratified by adherence into three categories: adhered well (observed taking over 90 % of treatment as prescribed); partially adhered (observed taking up to 50 % of treatment as prescribed); and LFT within the preceding 6 months. Sample recruitment was also stratified for patient characteristics, including gender and age. Health practitioners were identified to include MSF and MoH practitioners in a range of professions including doctors, nurses, and counsellors, who all had experience supporting and/or treating patients with MDR-TB.Patient participants were contacted by members of the psychosocial team with information about the study asking whether they would be willing to be interviewed. Interviews were arranged with those who agreed to take part at a time and location convenient for them, which was either at their home or in a private room at the DOT corner (outpatient TB department). Health practitioners were given information about the study by the principal investigator and asked if they would be willing to take part, with interviews then held in a private room of the project office or DOT corner.n = 52) were carried out by the principal investigator, the majority in the local language  with a trained interpreter, or in English. Interviews were participant-led and encouraged natural flow of conversation, based on topic guides to explore specific areas. Interviews lasted between 30 and 90 min, with an average duration of 60 min. Most interviews were audio recorded, unless participants refused consent for recording (n = 3), and were transcribed verbatim by the principal investigator if conducted in English (n = 4) or by an interpreter using equivalent translation from Karakalpak to English (n = 45), in order to maintain the integrity and meaning of data. Of the interviews transcribed by an interpreter, close to 50 % of these were transcribed and translated by an independent interpreter to maximise data validity. The three interviews that were not audio recorded were transcribed using notes. Topic guides for follow-up interviews were devised following review of initial interview transcripts and identification of areas to further explore. Data collection continued until new information was not being generated, therefore evidencing data saturation … I say that I don’t transmit this disease. Because I was not infected, I don’t know where I got it from. Otherwise none of our generations have had this, neither my own relatives nor here. P27The vast majority of patients described their MDR-TB developing through factors relating to “cold”, in terms of exposure to cold weather, wet ground, drinking cold water, or getting a cold. Many patients also understood their disease as having developed through not having looked after themselves, over-working, or through their immune system weakening, for example due to inadequate diet, giving birth, or physical trauma such as a car accident, which could lead to self-blame. For some participants, medical advice reportedly influenced these perceptions of disease development. A minority of participants believed they were infected with TB, or described their treatment history and drug resistance developing. Most patients asserted that they were not infected.[Medical staff] they say to women not to give birth for 5 years. They say that during the delivery the lung may dislocate, if there is a wound it may opened again, and it may start bleeding. P03They told us, they said “don’t lift anything more than 5 kg”, we submit to the discipline. P22Medical education or advice was described by some patients as restrictive for their health and wellbeing during and following treatment completion, including activities that must be avoided after treatment completion to avoid disease relapse, which contributed to patients’ fears about the permanence of cure.You should keep yourself clean. You should keep your dishes separate… I have separate towel. P26They [doctor] may be sitting with a TB patient in one room, but he sits like separating his dishes and avoiding touching that patient, but they are not afraid of sitting in one room [without respirator]. HP 11The majority of participants described TB transmission as occurring through materials or objects. Some described it as being hereditary and only a few described airborne transmission. Health practitioners also mentioned the belief that TB is transmitted through materials or objects existing among certain TB health staff.I came and had X-ray they said “you have a spot in your lung, you will go to TB2 [a hospital]”… They didn’t say anything. P12They said “your results are good but it is multi drug resistant type” and I asked what it was, they said that there was psychologist and we should see her. P18The information provided to and understood by patients during the diagnostic process often appeared to be inadequate, with many patients describing their diagnosis having been explained as a spot or symptom in their lung(s), without the opportunity to develop a better understanding. Patients reported receiving a brief explanation of their disease by doctors, with counsellors being relied upon for more expansive information.When they told me I didn’t understand. They told me and I was so much in shock that I even don’t remember what I was thinking about that time. P01If it is the first time that they were told that they have TB, even the health education part it’s too shocking… It seems like they were under a shocking period to accept the diagnosis even. HP 01During their diagnosis certain patients described being in a state of shock in which it was difficult to process the information given to them; this was echoed by most health practitioners.I started searching and I found that yes, this disease really exists, that this disease is really curable, that these drugs were not invented today nor yesterday, that they are being used for a long time, they use these drugs for more than 30–40 years. P01Several patients had taken an active approach to information seeking relating to their disease and treatment, involving using the internet, reading books, and asking their peers or others. This was also described by some health practitioners.If it is said by a person who takes the treatment it will be accepted… Because he knows how you used to suffer that’s why you believe him more than a healthy one. P01I know many patients who’d been given a “default” outcome, but now they are good…some of them have even started a job. P33Patient-to-patient information was seen to have more credibility in terms of quality, trust, and belief in the information source. Those who had passed through treatment themselves were perceived by patients as knowing its reality and assumed more likely to be honest and reliable. However, there could be the risk of negative peer influence, for example through LFT patients who appeared well despite not completing their treatment course.If they don’t have information, they won’t take treatment. HP 07If you believe in it then you will be cured. P21Several participants mentioned the significance of disease knowledge and understanding for acceptance and belief in treatment-taking. Some patients asserted that belief in the treatment efficacy and its impact on cure was the most important factor supporting the treatment-taking process. Most patients saw belief as being integral to the long and difficult treatment, giving strength to overcome its challenges.Day after day I take the drugs, months are passing, my cultures are good, turning to negative, every 6 months I am being x-rayed, everything is good. And because I see such results I believe… I believed that I can be cured with these drugs. P13Belief in treatment effect was reinforced through seeing symptoms and results improve, as well as seeing other patients recover. This instilled a sense of motivation and determination.The idea that they were telling me a lie was inside of me like a worm… I was like eating myself from inside not believing it P01They told me that it would be extended until September and after that I started hating it completely and I had missed about 20 days because of that. I lost my inspiration to take the drugs. P19Where patients doubted medical advice, including their diagnosis, and did not ascribe value to MDR-TB treatment, they appeared to be more vulnerable to misinformation, myths, and seeking alternative treatment. Doubt and distrust were reportedly exacerbated through changes in required treatment length and delays with accurate diagnosis (including awaiting drug sensitivity test results).In the streets people tell different information that there are some trials are being held in our region. P01Several patients and health practitioners described myths, such as treatment being provided as part of a foreign drug experiment in which drug efficacy was not known and was being tested. This was said to instil fear in some patients and deter them from taking treatment, and could be seen as demonstrative of patients’ distrust in the health system.Unless the doctor delivers him the information fully and explains in detail, that patient begins to look for that information from other people. HP 11So this time we also came home and I took dried apricots. And I felt a bit better. After that I was living normal, thinking that I was cured. P27Certain patients appeared to be conflicted about trusting medical advice but also wanting to find an easier option or believing myths and misinformation. This led to consideration of alternative treatment options, seen to be less lengthy and arduous, and was also reportedly fuelled through limited health knowledge and understanding.I still don’t believe I have had TB… they said I got this disease. We did not believe. It didn’t hurt anywhere. P27 [LFT patient]Some patients (in particular those LFT) did not believe they currently or had ever had TB. This was especially the case in asymptomatic patients, who expressed confusion linked to the lack of pain receptors in the lung. Disease denial and disbelief were seen as negatively impacting on treatment-taking.I took the drugs for about 6–7 months, you know, then my coughing stopped, I put on weight and then my mother-in-law said “you look good, you don’t look like you are sick, you don’t have to take the treatment”. P03 follow up [history of previous LFT]I said to myself I’m good, I won’t take the drugs for the rest of the time because I feel better. All the results were negative and good, and since I was also feeling good the rest was depending on me. P24 [LFT]Patients’ understanding and belief also influenced decision-making about when cure had been achieved. Several patients believed they had been cured, for example once their symptoms and/or results improved, and therefore stopped treatment before completing the full course, including many of the LFT participants.She really helped me much in continuing the treatment. P01I used to take treatment, take treatment well if I had a support from someone. P02Support and encouragement from family, counsellors, and peers were seen to help channel patients’ strength, motivation, and determination in continuing with treatment. Most patients cited their counsellor relationship as supporting treatment-taking.I talk to them [other patients] through the Agent , and you ask them at that time like “have you taken your drugs”, you give advice like “don’t miss”, then you meet often, that’s why we are taking the drugs. P23 follow-upPeer support was seen as providing a sense of shared experience and solidarity. Certain patients described forming their own peer support networks. For example, one patient had connected with other young MDR-TB patients, and they used social media daily to urge one another to take their treatment.Put a screen here, and we all sit together there and watch a short video, maybe for 10 min. And this video should show the patient with this disease and his way of treatment from the very beginning till the full completion, but do it in a very nice way. So that people who see it can believe in it. P13The need for more education and information about TB was highlighted by patients and health practitioners, at both the patient and community level. Suggestions were made for the use of a variety of mechanisms for information sharing, including interactive and multi-media based mediums such as film, radio, and television.The second emerging theme explores positive engagement with the treatment-taking process as reliant on patients’ sense of autonomy and ability to prioritise treatment over and above conflicting demands on their daily lives. This can be challenged by common beliefs, myths, and stigma about TB, as well as authoritative practitioner-patient relationships.I used to think of everything, like: “I am not able to do anything anymore”. I used to cry because of that. I was also thinking that I couldn’t look after my children. When I go home… I couldn’t do anything at home, couldn’t do anything. P11Treatment for MDR-TB was seen to have significant impact on daily life, requiring sacrifices relating to education, employment, and duties and responsibilities such as housework, as well as having social implications. Many patients said that they had worked prior to starting treatment, but were no longer able to do so. Patients described feeling so weak after taking the drugs that all they could do was to lie down; they couldn’t concentrate on studying and felt unable to care for their children or perform duties around the home.I was young at that time, around 16. Young heart, you know. And 2 years, oh, wow… you have to be separated from your friends and so on for 2 years. So I thought about that, about 2 years of separation. P19Single patients described feeling unable to marry until they had finished treatment, and several younger patients felt isolated from their friends and that they were missing out on activities that their peers were taking part in, such as attending events.I felt like healthy people were looking at me with disgust. P13Significant stigma was described by many participants, both perceived and enacted. Patients felt ashamed, as though people blamed them and looked at them differently because of their disease. They also described feeling ostracised and asserted wanting to hide their disease status.That constant condition of half a man, I used to feel like a half man. P01Actually there is nothing worse than staying at home and just take the drugs. I wish to complete this treatment, get cured, work like others, get salary, and attend celebrations and other events (crying). P34Many patients felt defined by their disease, their lives consumed by the routine of treatment-taking and side effects, separating them from a sense of normality and society. Some expressed a desire to feel equal, with a life beyond treatment and disease.While taking the treatment, my husband’s house were against… [they] wouldn’t let me take treatment… I took the drugs for about 6 months and then left, being a defaulter… What they say is: “we need someone who will serve us…” P03Gender and societal status were important determinants of patients’ autonomy and their ability to prioritise treatment. Most female patients who were, or had been, married described the implications of their role as daughter-in-law for treatment-taking. Many were expected to serve their husband’s family following marriage, with their position resulting in a lack of control over their health or lives. Some had severe difficulties continuing with treatment, including who described being seen as useless because side effects prevented their ability to perform household duties. Some patients were therefore unable to continue their treatment and only able to resume following divorce or leaving their husband’s family home, which was described as very difficult in the social context. Some female patients suggested that it could be better for daughter-in-law patients in this position to take treatment in hospital.There were some counter examples, with some married women asserting that they received support from their husband and in-laws. These patients seemed to live in separate homes from their in-laws, and in certain cases their family members had received treatment education through engagement with counsellors, described as particularly helpful in achieving their husband’s support.Due to my family reasons I couldn’t… I had to stop the treatment. Because there was no other source of income. P32 (LFT)Many male patients expressed frustration at not being able to work while on treatment, some highlighted their responsibility to provide for their family, with one LFT patient explaining that this was why he felt no choice but to stop treatment early. Socio-economic barriers to treatment-taking were reiterated by health practitioner participants.Recovery will be quick… my organism is young. P19Sometimes I don’t feel like taking that drug, you know. When I don’t feel like taking the drug, I say “I’ll stop from today on, I am 70 years old, that’s it, if I die it’s fine”. P12Age affected treatment-taking experience. Younger patients were perceived as being able to recover more quickly and better tolerate the drugs, whereas older patients expressed fatigue and found drug tolerance difficult, particularly if there were co-morbidities. Some older patients viewed themselves as having limited time left alive, with 2 years of treatment therefore being a significant burden. For certain younger patients, however, 2 years seemed a comparatively short period.I have my natural strength… I force myself every day, otherwise I won’t be able to take them. I can’t take them if I don’t push myself to it. P27Every man decides for himself… I need my health for my own sake. Because I need it for myself I have decided it. P21There are patients who become a defaulter because of social problems they have but there are also patients with social problems who are still trying to find a way out and to continue with the treatment to the end. HP 09Patients who described valuing their health and who were able to prioritise it above other demands demonstrated ownership, autonomy, and self-responsibility for the treatment-taking process, which drove them to persevere. These patients accounted strength of character and motivation as relevant to treatment-taking, alongside having aspirations and plans for their lives post-treatment, for example having a family, getting married, working, or studying. Strength of character was also acknowledged by health practitioner participants as important in overcoming challenges with treatment; some associated this with family background and education level.I used to have fear of their attitude. P13The doctors also get angry and they begged saying “take your drugs, take your drugs”… the doctors are also fed up with me. P14The power inherent in the practitioner-patient relationship was alluded to, with conflicting views about health practitioner communication style and approach. Certain patients described their relationship with doctors and nurses as positive, involving help and encouragement. Most of these patients seemed to be adherent, with some saying doctors praised them for their treatment-taking. Other patients highlighted the distrust that could exist within the relationship, and expressed being abused and threatened by doctors, and feeling angry about or afraid of practitioner attitudes. Some doctors were seen as just inspecting their treatment-taking, rather than performing full medical examinations and providing explanations. Patients described doctors begging them to take their drugs and feeling annoyed with them if they didn’t.The communication level should be very improved, patients should be seen as people… he should be a participator in his treatment… give space for patient to decide in his situation rather than one sided communication. HP 01Health practitioner participants highlighted the need for improved staff-patient communication, trust, mutual commitment, and respect. Practitioners explained that the staff-patient relationship impacted treatment adherence. A relationship that centred on blame and inspection of drug taking was seen to hinder patients’ ability to share adherence challenges. Begging patients to continue with treatment was seen to undermine their autonomy and self-responsibility for treatment-taking.How patients experience and perceive the impact of TB and treatment on their body presents the third and final theme. Such perceptions influence treatment tolerance and therefore the ability to continue to take treatment.I used to vomit until the evening… I used to feel dizzy, was almost about to fall down, felt so weak. Shivering… my hands and legs were shivering after vomiting. P25I take the drugs. Then I am knocked down… mouth full of saliva, feel drunk, don’t have any power to do anything. P27All patients described experiencing side effects at some point during treatment. A range of physical side effects were outlined, with many patients experiencing nausea and vomiting, loss of appetite, weakness, headaches, joint swelling, and pain, particularly in the legs. Patients stated experiencing dizziness and feeling drunk, changes in their appearance through skin discolouration, blurred vision, burning, itching, and diarrhoea. Psychological side effects were also described, including low mood, nervousness, loss of memory, and thinking negative, dark thoughts.In comparison to the initial stage of my treatment the difficulties I have now are much easier. I don’t suffer that much… I think my body got used to the drugs. P07Actually after the sixth…after the 7th or 8th month of treatment I realised that my body started refusing. P33Many patients viewed side effects as being worse at the beginning of treatment, reportedly becoming more tolerable after 2 to 3 months, when the body was said to adjust to the drugs. However, there were two exceptions to this, where patients’ side effects were considered to become worse over time, as their body started refusing the drugs.If you lose liver then you will die soon. If you lose lung you will live a bit longer… I said I wouldn’t take them anymore. I will spoil my liver, my liver will be destroyed. P27It’s like it has made all my bodies not function… all is ruined. P29Now I vomit because I am poisoned with the drugs. P33Some patients perceived treatment as poisoning other parts of the body, helping the lungs at the expense of the liver, kidneys, and stomach, for example. Some felt that their body was being ruined by drug toxicity, feeling unable to continue with treatment as a result, and fearing death from liver failure.I am fed up and refused completely. I stopped for 2 months. P18Certain patients expressed a sense of treatment fatigue, feeling that they had had enough of the burden of drug-taking and experiencing side effects each day. This was seen to undermine their motivation to continue with treatment and caused some patients to want a break. It was given as the reason for some stopping treatment or missing doses.When I took those drugs I suffered. I had been suffering for 2 years, vomiting, I couldn’t tolerate at all. I used to vomit for 2 years, it didn’t stop. P25We don’t take the tablet on Sundays… on those days I feel myself good like old times. P35Individuals were seen as tolerating drug side effects differently, with some patients not feeling able to tolerate the drugs at all. Certain patients found that tolerance became more difficult as the week progressed, with a perceived build-up effect, highlighting the importance of a rest day from treatment.If I take the anti-vomiting drug my drugs neither digest nor come out from my mouth. And I feel very bad. Better not to take anti-vomiting drug but try to keep the drugs for at least half an hour or an hour or so. P33Medical side-effect management had mixed reviews from patients and health practitioners. Some found that anti-side-effect drugs helped, others experienced no difference, and one patient felt worse with anti-emetic drugs. Several patients described feeling reluctant to try anti-side-effect drugs due to an aversion to increasing their pill intake. Health practitioners also described some patients hiding side effects to avoid increased pill burden. This factor limited the impact of medical support for side-effect tolerance and therefore adherence.If you suffer and you think of something bad you will not be able to take the drugs, it’ll be even worse. And if you are joyful and don’t think of anything bad then the drugs will not… [affect] you much. P11These drugs also can work depending on your mood. If a man is in a good mood then these drugs can be absorbed well and there might be no side effects. That’s why after you take the drugs you should….[think] positively P21When people have some hope, when people see life very happy they tolerate more or less better than people who are very depressed. HP 08A psychological ‘sphere’ to drug tolerance was described by many patients and health practitioners, with mood and mind set reportedly influencing the extent to which side effects were felt and experienced. This links to the concept of patients’ views around self, health, and the effect of the drugs. Focusing on positives was seen to lessen side effects and improve tolerance; whereas being around other patients discussing side effects and focusing on negatives was said to make treatment-taking and tolerance more difficult.I used to vomit when I saw them. P31You try to distract yourself a bit like you are taking only grapes. P33Some patients described using visualisation techniques to build a positive mind set, helping with drug tolerance. These included visualising the drugs helping the body, strengthening it and providing a cure, as well as tactics such as imagining the drugs were grapes or sweets. Conversely, some patients described developing a negative association with drugs, which led to them feeling nauseous at the sight or even thought of them, including drugs not related to MDR-TB.I come home after taking drugs and then go for a walk. That time you can forget, distract yourself… It helps to be distracted from the drugs. P19If you walk around or chat with someone, if you talk about something good to someone or listen to music then I think the drugs will digest well. P21Distractions from treatment were referred to as helping with drug tolerance and treatment-taking, which supports the notion of visualisation as a useful technique. Patients described activities such as walking outside, talking to friends or family, watching television, listening to music, or keeping busy in some way. Having distractions like these were said to be important, helping the days and treatment-taking pass more easily and improving mood.They say if a man is nervous then the vessels in lungs would be swollen and explode. P18Patients described different tactics to help them digest and tolerate the drugs, which varied for each individual. The coping mechanisms described included splitting doses or taking the drugs in one go, taking them with yoghurt or watermelon, lying down for 2–3 h after taking them, and performing mindfulness and meditation exercises with counsellor support. Food was mentioned as being important for drug tolerance, helping with taking the drugs and masking their taste, as well as reportedly improving side effects. Certain patients also highlighted the importance of a peaceful environment, with quarrelling, nervousness, and anger seen as undermining motivation for drug-taking, as well as worsening drug tolerance and disease progression.We found several factors that influenced the ability to adhere to MDR-TB treatment. Hope and high quality knowledge can support adherence; autonomy and control can enable optimal engagement with treatment-taking; and perceptions of the body, self, treatment, and disease can influence drug tolerance. As far as we are aware, the influence of patient autonomy and control on TB treatment-taking has not previously been described. In particular, we found that the autonomy of some married women around treatment-taking was undermined through their societal position as daughter-in-law, compromising their ability to adhere to treatment. We also found that patients’ engagement with treatment and adherence could be undermined through hierarchical practitioner-patient relationships that displaced authority, ownership, and responsibility from the patient.The importance of patient knowledge and information for adherence and retention in treatment has been documented . Lack ofIn the first theme that we identified, the presence of TB knowledge was seen to increase the likelihood of continuous engagement with treatment through influences on motivation, belief in the need for treatment and its efficacy, and hope for cure. Several patients, particularly those partially adherent or LFT, appeared to lack understanding about the implications of missing doses and the need to complete the full course of treatment. Certain patients defined themselves as cured once their symptoms improved or their culture results became negative, and thus stopped treatment before completing the full course. Several LFT patients did not believe they had TB despite receiving pre-treatment information and counselling during treatment. Doubt and distrust of the information received was expressed by several patients, exacerbated through changes in culture results and drug sensitivity test analyses. Some patients also appeared to be vulnerable to misinformation and myths, including those relating to alternative treatment options that were deemed to be less arduous and lengthy. Other studies have found that perceptions around cure and belief can cause adherence difficulties, with patients deciding they no longer need treatment once symptoms improve with treatment for MDR-TB  and drugThe active approach to information seeking expressed by several patients in our study could indicate insufficient provision of information from official sources within the programme. The patients who expressed actively seeking further information about their disease and treatment were all female, and most were young. Several participants expressed the need for more patient education, available in different formats and at different stages throughout the treatment course. This confirms the need to capitalise on the existing desire of patients for knowledge. Using mechanisms that enhance trust, such as peer-to-peer information could increase the likelihood of patients believing in the treatment. Certain patients also demonstrated a proactive approach to motivation through peer support by self-forming patient support networks. The patients who described valuing peer support were mostly young (under 30 years), male and female, and the majority were adherent. Counsellor and peer support was key to instilling hope for patients, similar to research showing that counsellor support is crucial for increasing patients’ belief in cure .In the second major theme we identified, patients’ autonomy and engagement around their treatment-taking was found to be influenced by social discourse on TB and authoritative relationships in their family, social, and medical lives. These affected patients’ ability to prioritise treatment over conflicting demands, as well as their sense of responsibility and ownership. Patients with resilience, intrinsic motivation, and who valued their health were said by health practitioners to be better able to continue with treatment and overcome its challenges. Treatment for many patients with MDR-TB has an impact on their sense of self and their lives through hindering their ability to work, study, and perform normal activities , 28. In The power inherent in the practitioner-patient relationship could shape patients’ interactions with their treatment. A “good patient, bad patient” dynamic was reflected, with some patients who adhered well reporting praise from doctors and nurses, whereas other patients felt blamed, shouted at, and inspected. This style of communication was seen to deter patients from feeling able to raise and discuss the challenges they were facing, and undermined their control and ownership over their treatment. This in turn led in some cases to a rebellious response from patients with regard to taking treatment, a response which has been explored further in Foucault’s work on the power dynamic and hierarchy within practitioner-patient relationships . Health The third theme we found highlights the relevance of disease embodiment and the ways in which a person perceives and interacts with treatment both physically and psycho-socially. The fact that all patients asserted experiencing side effects at some point in their treatment demonstrates the difficulties associated with taking such toxic drugs. Several patients described perceptions that the drugs were poisoning them, for example curing their lungs at the expense of other organs such as their liver. Other studies have reported patients’ experiences with side effects , 27, 28,Patients felt better able to tolerate the treatment if they had a more positive view of the drugs. Using techniques such as visualisation and distractions from treatment reportedly eased drug tolerance and therefore promoted drug-taking. Patients reported feeling drug side effects more acutely if they focused on them, or were around other patients suffering from them. At the same time, reinforcement of health care workers’ skills to support patients with long-term treatment and drug intake could help patients to believe in the chance of achieving a successful treatment outcome, which in turn could motivate good adherence to treatment.While identification of participants for potential recruitment in the study followed several steps, the role of health practitioners in approaching potential participants, informing them about the study and requesting their voluntary participation may have influenced recruitment in its reliance on their relationship with these individuals. However, as these health practitioners were predominantly counsellors who had supportive relationships with selected patients this should not have negatively influenced recruitment and may have encouraged participant openness. LFT participants took longer to identify and required adaptation of the recruitment approach to include direct introduction of the study by the Principal Investigator (PI). As we were unable to include patients who were abroad, this hindered exploration of their experiences with stopping treatment early. However, the financial and social responsibilities that can influence patients’ adherence have been portrayed, which may also have applied to these patients (some of whom likely migrated for employment reasons).It is acknowledged that participants could have shared a narrative that portrayed the account they thought the researcher wanted to hear; for example, health practitioner criticism was more directly described by practitioner participants than by patients, which could indicate an association of the researcher with the health programme. However, the fact that the researcher was not from the programme potentially countered this effect; participants were generally open regarding their experiences, views, and struggles. The role of the PI in shaping the data must also be acknowledged and reflected upon. While steps were taken to reduce researcher bias during the data collection and analysis process, for example through the review of coding and analysis by a second researcher, the PI’s involvement in designing the study, and in data collection and analysis, is likely to have influenced the study findings. As is to be expected in qualitative research, the concepts arising in this study may be generalisable to the larger population treated in the programme, but these may not be found in other contexts or in dissimilar settings.Patients experienced a variety of challenges throughout their treatment, reinforcing the need for an individualised and holistic approach to adherence support. This study suggests that quality knowledge, hope and belief, and patient autonomy and control can support MDR-TB treatment-taking; and that there is a psychological sphere to treatment which influences drug tolerance.Improving patients’ knowledge and understanding relating to TB treatment and disease could help them have the belief, hope, determination, and motivation to complete treatment. A space within which patients have a sense of authority and autonomy over their treatment must be created, for example through enhanced practitioner-patient communication and minimising social barriers, so that patients are active participants in their care and feel ownership and responsibility for their treatment. Finally, while adverse drug effects are experienced by the majority of patients, mechanisms have been found to help patients cope with and overcome difficulties with them and should be implemented as part of adherence strategies, such as the employment of visualisation techniques and distractions from treatment, which were found to ease the burden of side effects in this study.As we move towards the introduction of new drugs and treatment regimens for MDR-TB, the potential impact on adherence and how best patients can be supported should be considered as integral components of future studies and programmes.DOT, directly observed therapy; HP, health practitioner; LFT, loss from treatment; MDR-TB, multi-drug resistant tuberculosis; MoH, Ministry of Health; MSF, Médecins Sans Frontières; PI, principle investigator