Search

Abstract Background Emotion dysregulation commonly co-occurs with attention-deficit hyperactivity disorder (ADHD), leading to a range of negative outcomes. While psychological interventions have shown promise in bringing about positive changes in emotional and cognitive domains, there is still limited knowledge on the subjective experiences of change among the participants in these interventions. Aim The present study explores the experiences of adults with ADHD who had participated in a blended digital and face-to-face intervention aimed at improving emotion dysregulation. The study focuses on understanding their experiences of change and identifying contributors to change. Methods A total of 9 adults with ADHD participated in individual semi-structured, in-depth interviews following their participation in the intervention. The interviews were analyzed using thematic analysis. Results The thematic analysis resulted in three core themes. The first theme, ‘perceiving change’, represents changes that the participants experienced, with four subthemes: 1a) being in control, 1b) feeling aware, 1c) accepting oneself and one’s emotions and 1d) gaining insight and knowledge. The second theme, ‘supporting change’, captures factors that supported the participants’ changes, with five subthemes: 2a) acquiring skills, 2b) being in it together, 2c) therapist guidance, 2d) finding motivation 2e) putting it into practice. Lastly, the third theme, ‘sustaining change’, includes aspects important to maintain change, with two subthemes: 3a) working consistently and 3b) giving it time. Conclusions The findings show that the participants experienced various changes related to the management of their emotions following their participation in the intervention. Change was perceived as a multifaceted process, supported by internal factors such as motivation and engagement, along with external factors such as support from the other group members and the therapists. Taken together, the findings from the study could be important to the development of psychological interventions for adults with ADHD and may provide valuable knowledge to clinicians and policymakers. Trial registration Registered on 21st November 2022 at ClinicalTrials.gov. ClinicalTrials.gov ID: NCT05644028.

This qualitative study explores the role of identity in changing from a traditional, organisation-based career to a protean career path. Biographical narrative interviews were conducted with 12 prime-aged U.K. participants. Data were analysed using narrative and thematic analysis. Findings highlight the anchoring role of identity in transitioning to a career driven by values, and demonstrating adaptability in an unpredictable work environment. Findings are used to propose a definition of identity relevant to protean career changers, and to suggest that clear identity should be considered "the" core characteristic necessary for thriving in transitions to protean career paths. Career practitioners are advised to prioritise identity exploration with clients seeking to transition from an organisation-based career to pursue a self-directed, values-driven career path.

Abstract BackgroundThe symptoms and associated characteristics of attention-deficit/hyperactivity disorder (ADHD) are typically assessed in person at a clinic or in a research lab. Mobile health offers a new approach to obtaining additional passively and continuously measured real-world behavioral data. Using our new ADHD remote technology (ART) system, based on the Remote Assessment of Disease and Relapses (RADAR)–base platform, we explore novel digital markers for their potential to identify behavioral patterns associated with ADHD. The RADAR-base Passive App and wearable device collect sensor data in the background, while the Active App involves participants completing clinical symptom questionnaires. ObjectiveThe main aim of this study was to investigate whether adults and adolescents with ADHD differ from individuals without ADHD on 10 digital signals that we hypothesize capture lapses in attention, restlessness, or impulsive behaviors. MethodsWe collected data over 10 weeks from 20 individuals with ADHD and 20 comparison participants without ADHD between the ages of 16 and 39 years. We focus on features derived from (1) Active App (mean and SD of questionnaire notification response latency and of the time interval between questionnaires), (2) Passive App (daily mean and SD of response time to social and communication app notifications, the SD in ambient light during phone use, total phone use time, and total number of new apps added), and (3) a wearable device (Fitbit) (daily steps taken while active on the phone). Linear mixed models and td ResultsGroup differences were significant for 5 of the 10 variables. The participants with ADHD were (1) slower (PdPdPdPdPdPPdPdPdPdPd ConclusionsIn a novel exploration of digital markers of ADHD, we identified candidate digital signals of restlessness, inconsistent attention, and difficulties completing tasks. Larger future studies are needed to replicate these findings and to assess the potential of such objective digital signals for tracking ADHD severity or predicting outcomes.

Scholars have long debated the merits of advocacy-based research versus research considered from the quest for objective truth. Building upon reflections from multiple sources, a set of 11 brief reflections on three posed questions are presented. Tsang concludes our discussion with additional insights on how moving beyond the “interestingness” advocacy will be beneficial to the continued professional development of the management discipline.

Production of high-quality multiple-choice questions (MCQs) for both formative and summative assessments is a time-consuming task requiring great skill, creativity and insight. The transition to online examinations, with the concomitant exposure of previously tried-and-tested MCQs, exacerbates the challenges of question production and highlights the need for innovative solutions. Several groups have shown that it is practical to leverage the student cohort to produce a very large number of syllabus-aligned MCQs for study banks. Although student-generated questions are well suited for formative feedback and practice activities, they are generally not thought to be suitable for high-stakes assessments. In this study, we aimed to demonstrate that training can be provided to students in a scalable fashion to generate questions of similar quality to those produced by experts and that identification of suitable questions can be achieved with minimal academic review and editing. Second-year biochemistry and molecular biology students were assigned a series of activities designed to coach them in the art of writing and critiquing MCQs. This training resulted in the production of over 1000 MCQs that were then gauged for potential by either expert academic judgement or via a data-driven approach in which the questions were trialled objectively in a low-stakes test. Questions selected by either method were then deployed in a high-stakes in-semester assessment alongside questions from two academically authored sources: textbook-derived MCQs and past paper questions. A total of 120 MCQs from these four sources were deployed in assessments attempted by over 600 students. Each question was subjected to rigorous performance analysis, including the calculation of standard metrics from classical test theory and more sophisticated item response theory (IRT) measures. The results showed that MCQs authored by students, and selected at low cost, performed as well as questions authored by academics, illustrating the potential of this strategy for the efficient creation of large numbers of high-quality MCQs for summative assessment.

Background and aims Individuals living with severe mental illness such as schizophrenia and bipolar can have significant emotional, cognitive, physical and social challenges. Most people with severe mental illness in the United Kingdom do not receive specialist mental health care. Collaborative care is a system of support that combines clinical and organisational components to provide integrated and person-centred care. It has not been tested for severe mental illness in the United Kingdom. We aimed to develop and evaluate a primary care-based collaborative care model (PARTNERS) designed to improve quality of life for people with diagnoses of schizophrenia, bipolar or other psychoses when compared with usual care. Methods Phase 1 included studies to (1) understand context: an observational retrospective study of primary and secondary care medical records and an update of the Cochrane review ‘Collaborative care approaches for people with severe mental illness’; (2) develop and formatively evaluate the PARTNERS intervention: a review of literature on collaborative care and recovery, interviews with key leaders in collaborative care and recovery, focus groups with service users and a formative evaluation of a prototype intervention model; and (3) develop trial science work in this area: a core outcome set for bipolar and recruitment methods. In phase 2 we conducted a cluster randomised controlled trial measuring quality of life using the Manchester Short Assessment of Quality of Life and secondary outcomes including time use, recovery and mental well-being; a cost-effectiveness study; and a mixed-methods process evaluation. Public involvement underpinned all of the workstream activity through the study Lived Experience Advisory Panel and the employment of service user researchers in the project team. Results phase 1 The study of records showed that care for individuals under secondary care is variable and substantial and that people are seen every 2 weeks on average. The updated Cochrane review showed that collaborative care interventions were highly variable, and no reliable conclusions can be drawn about effectiveness. The PARTNERS model incorporated change at organisational, practitioner and individual levels. Coaching was selected as the main form of support for individuals’ personal goals. In the formative evaluation, we showed that more intensive supervision and ‘top-up’ training were needed to achieve the desired shifts in practice. A core outcome set was developed for bipolar, and measures were selected for the trial. We developed a stepped approach to recruitment including initial approach and appointment. Results phase 2 The trial was conducted in four areas. In total, 198 participants were recruited from 39 practices randomised. Participants received either the PARTNERS intervention or usual care. The follow-up rate was 86% at 9–12 months. The mean change in overall Manchester Short Assessment Quality of Life score did not differ between the groups [0.25 (standard deviation 0.73) for intervention vs. 0.21 (standard deviation 0.86) for control]. We also found no difference for any secondary measures. Safety outcomes (e.g. crises) did not differ between those receiving and those not receiving the intervention. Although the costs of intervention and usual care were similar, there is insufficient evidence to draw conclusions about the overall cost-effectiveness of PARTNERS. The mixed-methods process evaluation demonstrated that a significant proportion of individuals did not receive the full intervention. This was partly due to care partner absence and participant choice. The in-depth realist informed case studies showed that participants generally appreciated the support, with some describing having a ‘professional friend’ as very important. For some people there was evidence that delivery of the intervention had led to specific personal changes. Strengths and limitations The phase 1 records study provided insights into usual care that had not been previously documented. The realist informed complex intervention development was both theoretical and pragmatic. The trial continued through the COVID-19 pandemic with high levels of follow-up. The process evaluation had the depth to explore individual changes in participants’ response to the intervention. Weaknesses in the trial methodology included suboptimal implementation, outcome measures that may not have been sensitive to changes patients most appreciated and difficulties collecting some outcomes. Conclusions While PARTNERS was not shown to be superior to usual care, the change to PARTNERS care was not shown to be unsafe. Full intervention implementation was challenging, but this is to be expected in studies of care that include those with psychosis. Some individuals responded well to the intervention when psychological support in the form of individualised goal setting was flexibly deployed, with evidence that having access to a ‘professional friend’ was experienced as particularly helpful for some individuals. Future work Key components of the PARTNERS model could be developed further and tested, along with improved supervision in the context of ongoing community mental health care change. Trial registration This trial is registered as ISRCTN95702682. Funding This award was funded by the National Institute for Health and Care Research (NIHR) Programme Grants for Applied Research programme (NIHR award ref: NIHR200625) and is published in full in Programme Grants for Applied Research; Vol. 12, No. 6. See the NIHR Funding and Awards website for further award information. Plain language summary Over 7 years, the PARTNERS2 research programme co-developed and evaluated a new way of working to support people with schizophrenia, bipolar or other psychoses in order to fill the gap in provision between primary care and secondary mental health services. The intervention involved a ‘care partner’ and followed a collaborative care approach. We completed several studies, including a full randomised controlled trial, in four sites: Birmingham, Cornwall, Plymouth and Somerset. We found the following: Analysis of secondary care records showed that many individuals received a lot of specialist care contacts that are not visible in primary care records. Our outcomes work for bipolar identified several themes, including personal recovery, connectedness, clinical recovery and mental health/well-being. These helped us choose quality of life as the primary outcome for the PARTNERS2 trial. Our preliminary work developing the ‘care partner’ collaborative care coaching approach was well received but showed problems with delivery, including supervision. The full trial was completed despite the COVID-19 pandemic but with fewer participants (a total of 198) than intended. No differences were found between those receiving and those not receiving PARTNERS care. Some participants received little or no intervention, partly due to care partner absences. The care partner approach was appreciated by some service users whom we interviewed for feedback. They described positive benefits of working with a ‘professional friend’ but only more limited examples of longer-term impact. Care partners sometimes appeared to take time to learn to put joined-up individualised care into practice. Although the PARTNERS2 trial produced a neutral result – meaning that people were no worse or no better as a result of receiving primary-care-based collaborative care – there are both practical and theoretical reasons that are likely to explain this. As the PARTNERS approach aligns well with current mental health policy, we are continuing to test the approach in practice. Scientific summary Background People with a diagnosis of schizophrenia, bipolar or other psychoses have a significantly reduced life expectancy; two-thirds of this mortality gap can be explained by physical health disparities. For many people with severe mental illness, about 1% of the population, their primary and secondary mental health care is delivered by separate teams, causing a negative impact on continuity of care. The PARTNERS1 study found that nearly one-third of people with severe mental illness in the UK were seen only in primary care, and other studies show that more than a half of individuals receive no specialist input. A significant policy shift in the UK prioritises the better integration of place-based mental health systems involving primary and secondary care, the voluntary sector and local authorities. Collaborative care is a system of care that includes clinicians from primary and secondary care working together, proactive review and psychological support. Previous studies have mostly included populations with depression and anxiety, who have different challenges from individuals with serious mental illness. Most of the work on collaborative care for serious mental illness has been in the USA, where the nature of service user populations and of service use differ from the way we fund, structure and use the NHS. Research into effectiveness is, so far, equivocal. Aims, objectives and summary of approach The aim of the PARTNERS2 research programme was to co-develop and evaluate a model of collaborative care for people diagnosed with schizophrenia, bipolar and other forms of psychosis in addition to usual care, in comparison with usual care alone. The programme was carried out between 2014 and 2021, adapting according to circumstances, and included: Phase 1: development work (2014–7) – describing the context of current care delivery by assessment of support provided to people with SMI in three areas of England, including investigation of collaborative care evidence (workstream 1) developing a theoretical model of the intervention (workstream 3) developing trial methodology (workstreams 2, 4 and 5). Phase 2: full trial and process evaluation (2017–21) (workstream 6) – a randomised controlled trial a health economics analysis a parallel process evaluation to examine fidelity, evaluate process of delivery and further develop the programme theory for implementation. The programme was co-produced with our patient and public involvement team, including the Lived Experience Advisory Panel. The originally planned external pilot trial was replaced with an internal pilot trial feeding into a fully powered randomised controlled trial. Phase 1 Understanding context Method An observational retrospective cohort study of primary and secondary care medical notes (2012–4). A total of 297 participants with serious mental illness under a specialist were selected from three participating mental health services (West Midlands, Lancashire and Devon). An update of our original Cochrane review ‘Collaborative care approaches for people with severe mental illness’. Results From the notes review activity, we found that for individuals with serious mental illness who are in contact with secondary mental health services, these services are centrally involved in their care. On average, three-quarters of all direct contacts were from secondary care, and individuals were seen on average every 2 weeks. These individuals were also seen on average every 6 weeks in primary care. However, a significant minority (12%) did not receive any specialist care. The Cochrane update comprised 8 randomised controlled trials, with a total of 1165 participants for review. The trials provided data for comparison between collaborative care and standard care. Collaborative care interventions varied a lot. There was no evidence that they are more effective than standard care; however, confidence in these findings is limited. Development of the intervention Method A realist informed approach was taken to identify underlying mechanisms and to integrate findings as an initial model from: a review of the literature on collaborative care for mental health (from workstream 1) and personal recovery literature interviews with key leaders in collaborative care and personal recovery to explore their perceptions about best practice (n = 11) focus groups with service users about their experiences of care (n = 33). The intervention was delivered by care partners at the three sites to those recruited for pilot work. A formative evaluation of this initial model used semistructured interviews with practitioners, service users, carers, general practitioners and secondary care practitioners along with recordings of interactions to adapt the intervention. Results Researchers extracted ‘explanatory statements’ representing candidate mechanisms that could make collaborative care effective. These were consolidated to 106 statements and used to develop the programme theory for the initial model. This was represented graphically and in a manual for practitioners and in guides for service users and carers. The PARTNERS intervention involves change at three levels: institutional level (secondary care trusts/Community Mental Health Teams and primary care), practitioner level (care partners, supervisors, other primary and secondary care staff, third-sector and community organisational staff) and service user level (service users and friends and family, where there was consent). The manual details how practitioners should work flexibly to provide person-centred care through a coaching approach. The formative evaluation found that some aspects of implementation were not always delivered as expected, particularly interaction with primary care teams, the use of coaching and the supervision of practitioners. The model was further refined based on these results, with added training and support for the care partners in the main trial. Development of trial methodology Method A core outcome set was developed for bipolar using three stages and with Lived Experience Advisory Panel input: A long list of outcomes was derived from focus groups with people with a bipolar diagnosis and their carers, interviews with healthcare professionals and a rapid review of outcomes used in trials. An expert panel with personal and/or professional experience of bipolar participated in a two-stage online Delphi survey, with 50 participants in round 1 and 33 in round 2. A consensus meeting was held to finalise the core outcome set. Outcomes and associated measures for the randomised controlled trial were selected using a further consensus meeting, which took into account the wider population and nature of intervention. The feasibility of trial processes was tested in the formative evaluation study. Different methods of approaching potentially suitable individuals using primary and secondary care databases, and involving practitioners, were tested. These took into account legal and research governance requirements while prioritising an ambition to include those individuals considered most likely to benefit from support. Results The Delphi survey included 66 outcomes, and participants were invited to add others. A consensus meeting generated the final core outcome set consisting of 11 outcome domains: personal recovery; connectedness; clinical recovery of bipolar symptoms; mental health; well-being; physical health; self-monitoring and management; medication effects; quality of life (QoL), service outcomes; service user experience of care; and use of coercion. Quality of life was selected as the most important outcome domain for the proposed PARTNERS2 trial. The Manchester Short Assessment of Quality of Life (MANSA) was selected because it was clinically relevant to the target population and potentially amenable to change by the intervention. To test approach procedures, we recruited 37 participants across three sites. Those eligible from secondary care were approached by a clinician known to them. Those seen in primary care received an invitation letter with an expression of interest from the general practitioner practice. Two strategies were tested to improve recruitment among those who did not respond to initial contacts: a telephone call from a clinician or the research team to discuss the study an ‘appointment letter’ inviting them to a short meeting at the practice to discuss the study. Both approaches were acceptable to participants and added to recruitment. Phase 2 Internal pilot and randomised controlled trial Method The cluster randomised trial recruited in four areas (Birmingham and Solihull, Cornwall, Plymouth and Somerset), involving 39 general practices. In total 198 participants were recruited, and practices were randomised (1 : 1 allocation) so that individuals received either the PARTNERS intervention (20 practices, 116 participants) or usual care only (19 practices, 82 participants). The PARTNERS intervention involved a trained secondary mental healthcare worker in primary care (a ‘care partner’) working collaboratively with the participant, primary care, secondary care and other organisations, aiming to improve the participant’s QoL, mental health and physical health care. Participants received the intervention for up to 12 months, including a 2-month transition period back to usual care only. During the COVID-19 pandemic, the intervention was moved online (using telephone calls and video conferencing). All participants allocated to the control arm of the trial continued to receive usual care, either within primary care only or also with secondary care. At baseline, the following data were collected: QoL (MANSA), Time Use Survey (ONS TUS), general health status (EuroQol-5 Dimensions, five-level, Warwick–Edinburgh Mental Wellbeing Scale), capability measure (ICEpop CAPability) and experience of care (Brief-INSPIRE). All assessments were completed again at the follow-up visit (10 months from the point of unmasking), as was an extra questionnaire on the impact of COVID-19 for participants recruited during the pandemic. Results Primary outcome data were available for 99 (85.3%) intervention and 71 (86.6%) control participants. Mean change in overall MANSA score did not differ between the groups [0.25 (standard deviation 0.73) for intervention vs. 0.21 (standard deviation 0.86) for control]; the estimated fully adjusted between-group difference was 0.03 (95% confidence interval −0.25 to 0.31; p = 0.819). None of the secondary outcomes differed significantly between the groups. Acute mental health episodes (safety outcome) included three crises among those who received the intervention and four among those who did not. Cost effectiveness analysis Methods The economic evaluation aimed to estimate the cost-effectiveness of PARTNERS2 compared with usual care. Quality-adjusted life-years measured health benefit. Patient-level service use data were costed using national unit costs for 2019–20. The primary outcome was the incremental cost-effectiveness ratio, which combines service use costs and health benefit. Participant-reported service use at follow-up was collected for a 3-month recall period. The planned audit of primary and secondary care notes was not feasible given the impact of the COVID-19 pandemic. Regression analysis estimated the net costs and quality-adjusted life-years of PARTNERS2, adjusting for key covariates. Results Using the multiple imputed data, the average quality-adjusted life-years (usual care: mean 0.55, 95% confidence interval 0.48 to 0.61; PARTNERS2: mean 0.51, 95% confidence interval 0.45 to 0.57) and costs (usual care: mean £2689, 95% confidence interval £999 to £4378; PARTNERS2: mean £1743, 95% confidence interval £1149 to £2338) were similar for the two groups. Overall, the 95% confidence intervals are wide and overlap, indicating a high level of variance and uncertainty. The net, bootstrapped quality-adjusted life-years (−0.007, 95% confidence interval −0.086 to 0.071) and costs (−£213, 95% confidence interval −£1030 to £603) were similarly inconclusive, with wide 95% confidence interval that overlapped zero. At the prespecified willingness-to-pay threshold of £15,000 to gain one additional quality-adjusted life-year, the probability that the PARTNERS2 intervention is cost-effective is

Aims: The diagnosis of periprosthetic joint infection (PJI) can be challenging as the symptoms are similar to other conditions, and the markers used for diagnosis have limited sensitivity and specificity. Recent research has suggested using blood cell ratios, such as platelet-to-volume ratio (PVR) and platelet-to-lymphocyte ratio (PLR), to improve diagnostic accuracy. The aim of the study was to further validate the effectiveness of PVR and PLR in diagnosing PJI. Methods: A retrospective review was conducted to assess the accuracy of different marker combinations for diagnosing chronic PJI. A total of 573 patients were included in the study, of which 124 knees and 122 hips had a diagnosis of chronic PJI. Complete blood count and synovial fluid analysis were collected. Recently published blood cell ratio cut-off points were applied to receiver operating characteristic curves for all markers and combinations. The area under the curve (AUC), sensitivity, specificity, and positive and negative predictive values were calculated. Results: The results of the analysis showed that the combination of ESR, CRP, synovial white blood cell count (Syn. WBC), and polymorphonuclear neutrophil percentage (PMN%) with PVR had the highest AUC of 0.99 for knees, with sensitivity of 97.73% and specificity of 100%. Similarly, for hips, this combination had an AUC of 0.98, sensitivity of 96.15%, and specificity of 100.00%. Conclusion: This study supports the use of PVR calculated from readily available complete blood counts, combined with established markers, to improve the accuracy in diagnosing chronic PJI in both total hip and knee arthroplasties. Cite this article: Bone Jt Open 2023;4(11):881–888.

Abstract Background This paper explores the extent to which the implementation and evaluation of a collaborative care model of face-to-face service delivery for people with severe mental illness was viable during the first UK lockdown associated with COVID-19. The PARTNERS2 cluster randomised controlled trial and process evaluation were co-designed with service users and carers. The aim of this paper is to explore whether digital adaptation of the PARTNERS model for people with severe mental illness during the COVID-19 lockdown was equitable, in terms of fostering collaboration and trust in a vulnerable population. Results We collected qualitative data from multiple sources during lockdown and subsequently constructed case-studies of participating secondary care workers. We adopted Bauman’s notions of liquid modernity to inform our analysis, and identified that digital adaptation during lockdown was only successful where organisational policies, care partner skills and service users’ existing resources were optimal. Conclusion PARTNERS2 can be delivered digitally by a care partner to support people with severe mental illness to identify and work towards their goals when existing resources are optimal. However, at a time of increased need, we identified that people who are very unwell and living with limited access to resources and opportunities, remained disenfranchised at great cost. Trial registration ISRCTN 95702682, registered 26.10.2017

Abstract After stroke, impaired motor performance is linked to an increased demand for cognitive resources. Aerobic exercise improves cognitive function in neurologically intact populations and may be effective in altering cognitive function post-stroke. We sought to determine if high-intensity aerobic exercise paired with motor training in individuals with chronic stroke alters cognitive-motor function and functional connectivity between the dorsolateral prefrontal cortex (DLPFC), a key region for cognitive-motor processes, and the sensorimotor network. Twenty-five participants with chronic stroke were randomly assigned to exercise (n = 14; 66 ± 11 years; 4 females), or control (n = 11; 68 ± 8 years; 2 females) groups. Both groups performed 5-days of paretic upper limb motor training after either high-intensity aerobic exercise (3 intervals of 3 min each, total exercise duration of 23-min) or watching a documentary (control). Resting-state fMRI, and trail making test part A (TMT-A) and B were recorded pre- and post-intervention. Both groups showed implicit motor sequence learning (p

A critical goal for science education is to design and implement learning activities that develop a deep conceptual understanding, are engaging for students, and are scalable for large classes or those with few resources. Approaches based on peer learning and online technologies show promise for scalability but often lack a grounding in cognitive learning principles relating to conceptual understanding. Here, we present a novel design for combining these elements in a principled way. The design centers on having students author multiple-choice questions for their peers using the online platform PeerWise, where beneficial forms of cognitive engagement are encouraged via a series of supporting activities. We evaluated an implementation of this design within a cohort of 632 students in an undergraduate biochemistry course. Our results show a robust relationship between the quality of question authoring and relevant learning outcomes, even after controlling for the confounding influence of prior grades. We conclude by discussing practical and theoretical implications.

No artigo, a pesquisadora Denyer problematiza o papel das mulheres no teatro de animação da África Ocidental a partir das trajetórias e de entrevistas com as artistas africanas Liking, Tsikplonou e Bacco. Relata e analisa suas práticas nos grupos de teatro africanos Ki-Yi Puppets & Dances, Evago e Bouam, respectivamente, evidenciando que estas mulheres criaram novas formas de pensar o teatro de animação na África. Afirma que elas criaram figuras pós-tradicionais no teatro de formas animadas que subvertem as expectativas culturais e conscientizam o público para temas como saúde, educação e preconceitos sociais durante os espetáculos.