Nitrofurantoin is a nitrofuran antibiotic that has been used for treatment of urinary tract against positive and negative bacteria.The aim of this study was to evaluate the effect of structural vehicles and flocculating agents on physical stability and rheological behavior of nitrofurantoin suspension.To formulate the suspensions, the effect of glycerin and polysorbate 80 as wetting agents was evaluated and their particle sizes were determined using the sieve method. Then to achieve controlled flocculation, sodium citrate and aluminum chloride were added. After choosing the suitable wetting and flocculating agents, structural vehicles such as sodium carboxyl methyl cellulose and Veegum were evaluated individually and in combination. In addition, the effect of sorbitol on density of continuous phase and some physical stability parameters such as sedimentation volume, degree of flocculation and ease of redispersion of the suspensions were evaluated. After incorporation of structural vehicles, the rheological properties of formulations were also determined to find their flow behavior.According to the results, glycerin (0.2%) and sodium citrate (0.3%) had the best effect on the suspension stability as wetting and flocculating agents, respectively. Rheological properties of formulations showed pseudoplastic behavior with some degree of thixotropy.In conclusion, the suspension containing Veegum 1%, sodium carboxy methyl cellulose 1%, glycerine 0.2%, sodium citrate 0.3% and sorbitol 20 % was chosen as the most physically stable formulation. Nitrofurantoin is a synthetic nitrofuran that has been commonly used for treatment of urinary tract and gastrointestinal infections. Nitrofurantoin is commercially available as tablets or oral suspensions and parenteral liquid. The drug has numerous toxic effects such as pulmonary and hepatic toxicity. Nitrofurantoin is not able to penetrate body tissues well, so it should not be used for treatment of kidney or prostate infections -5. A susThe aim of the present study was to evaluate the effect of structural vehicles and flocculating agents on physical stability and rheological behavior of nitrofurantoin suspension.Glycerin, polysorbate 80, sorbitol, aluminum chloride and Veegum were purchased from Merck, Germany. Sodium citrate was obtained from Kia Behsam Chemie (K.B.C), IR Iran. Sodium carboxy methyl cellulose (NaCMC) and nitrofurantoin were purchased from NoviAnt, Sweden and Ubichem, England, respectively.Polysorbate 80 (0.2%) and glycerin (0.2%) were used as wetting agents. The concentration of nitrofurantoin was 0.5%. Their particle sizes were determined using sieves methods. Twenty-five milliliters of distilled water was added to the polysorbate and glycerin and this mixture was then gradually added to nitrofurantoin powder. The total volume of the suspension was 50 mL. Composition of different formulations of nitrofurantoin suspension including wetting agents and their particle sizes are shown in To achieve controlled flocculation, different concentrations of sodium citrate  and aluminum chloride  were added to the suspensions. For decreasing of sedimentation volume of the suspension, sorbitol with concentrations of 15% and 20% was used. By comparison of their sedimentation volume and improvement of their appearance, suitable wetting and flocculating agents were chosen and then different structural vehicles were added. The effect of Veegum , NaCMC , and their combination as structural vehicles was evaluated.u/Vo,After preparation, the suspensions were kept in a graduated cylinder and their sedimentation volume was measured daily. The heights of sediments were measured when there was no change in three consecutive readings. Their sedimentation volumes were calculated using the following formula; F = Vu and Vo are volume of sediment and volume of suspension, respectively.where F is sedimentation volume, and V∞,Unflocculated 0.5% nitrofurantoin suspension was prepared in the absence of wetting and flocculating agents and stored at room temperature. When the sedimentation volume remained unchanged, the degree of flocculation was calculated using the following formula; β = F/F∞ are sedimentation volume of flocculated and deflocculated suspensions, respectively.where β is the degree of flocculation, and F and FThe suspension samples were placed in glass cylinders and rotated periodically around 360 degrees until thorough dispersion was achieved. The number of rotations needed for complete redispersion was recorded. Redispersion was evaluated by visual observation (N).The rheological behavior of nitrofurantoin suspensions in different formulations  was deteKruskal-Wallis test followed by Conover-Inman test for multiple-comparison were performed to compare sedimentation volumes, the degrees of flocculation and the ease of redispersion. For all analyses, statistical significance was assessed at a level of 0.05 using analysis. The data are shown as the median and range of at least three measurements.4 and F5, the sediments in suspension containing glycerin were dispersed easily in comparison with suspensions containing polysorbate 80. Particles size is an important factor that affects the solubility and stability of suspensions. High sedimentation volume was observed in formulations F4 and F5 that had used sieving size of 200 and 230 meshes, respectively and showed no significant difference with other formulations of suspension containing glycerin (P > 0.05). Regarding their ease of redispersion due to formation of cake, formulations F4 and F5 were significantly different from other formulations containing glycerin (P < 0.05). This phenomenon may be occurring due to increase of contact surface and accumulation of particles that results from particles size decrease. Different formulations of suspensions containing polysorbate 80 showed no significant change in their ease of redispersion and sedimentation volume (P > 0.05). According to median values of F, N and b for nitrofurantoin suspension in different formulations of glycerin and polysorbate 80  had the best effect on reducing sedimentation volume. Results of rheologic study showed that all of the formulations had pseudoplastic behavior with some degree of thixotropy . The valbehavior .9 and F11) had antithixotropy behavior. Thus, formulation F10 was selected as the best formulation. It is suggested that low concentration of NaCMC may affect the rheological behavior of suspensions and the highest improving effect may be achievied by using higher concentrations of NaCMC.Regarding the results of sedimentation volume and the ease of redispersion, suspension containing Veegam 1% and NaCMC 0.5% was chosen as the best formulation. However, the results of the rheological study showed that these formulations (Fin vitro release of lumiracoxib from poloxamer gels. The results of the rheological study showed a pseudoplastic behavior, and an increase of poloxamer from 20% to 30% w/w and oleic acid increased the viscosity of the gel (Rheological properties of suspensions depend on their particle size, shape and surface modification . Viriyar the gel .Khunawat the gel . Li et a the gel .The combination of glycerin 0.2% and sodium citrate 0.3% showed the best wetting and flocculating properties. Rheological studies showed pseudoplastic behavior. In conclusion, in different formulations of nitrofurantoin suspension regarding their F, N and β, the suspension containing Veegum 1%, sodium carboxy methyl cellulose 1%, glycerin 0.2%, sorbitol 20 % and sodium citrate 0.3% was the most physically stable formulation and showed the most proper rheological behavior.


The past decade has seen an increased number of state-civil society partnerships in the global Human Immunodeficiency Virus/Acquired Immune Deficiency Syndrome (HIV/AIDS) response of many countries. However, there has been limited research carried out concerning the successes and challenges of these partnerships.In-depth qualitative interviews were conducted with 23 participants from 21 different state-civil society partnerships throughout Ghana including all three major geographical zones  to examine the nature of these partnerships and their positive and negative effects in responding to the national HIV/AIDS epidemic.Major themes included: 1) commitment by the government and civil society organizations to work cooperatively in order to support the development and implementation of HIV/AIDS interventions in Ghana; 2) the role of civil society organizations in facilitating community mobilization; capacity building; and information, resources and skills exchange to increase the efficiency and effectiveness of these partnerships for HIV prevention and treatment; and 3) significant challenges including funding issues and other structural barriers for these partnerships that need to be addressed moving forward.Future research should focus on examining the impact of recommended changes on state-civil partnerships and studying the extent and nature of these partnerships in other countries in order to establish the generalizability of the findings from this study.The online version of this article (doi:10.1186/s12913-016-1598-9) contains supplementary material, which is available to authorized users. The last decade has seen an increasing proliferation of state-civil society partnerships for Human Immunodeficiency Virus/Acquired Immune Deficiency Syndrome (HIV/AIDS) prevention, treatment, care and support in at least 35 sub-Sahara African countries, which includes Ghana, Kenya, Uganda, Tanzania, Nigeria and Malawi , 2. The These global change processes have tended to alter the balance between state and market to produce a system of organizational arrangements for the delivery of health care services. This is particularly striking in developing countries where Civil Society Organizations (CSOs) that include Non-Governmental Organizations (NGOs), Faith-Based Organizations (FBOs), and Community-Based Organizations (CBOs) now supplement, and in some cases have displaced the traditional role of the state in health care –13. ThusCSOs, likewise, in their quest to expand the scope of their service delivery and advocacy activities, are progressively engaged in actions resulting in strategic alliances with the state in the fight against the HIV/AIDS epidemic. This signals change in the longstanding organizational system supporting the national HIV/AIDS response and in the form and functions of CSOs themselves, as they try to adjust to new roles and models for social services delivery. While these novel methods of organizing and delivering services have been unfolding across developing countries for a number of years, there has been limited research regarding their drivers, structure, successes and challenges –16. UndeThe Ghana AIDS Commission (GAC) was established in 2002 as the highest coordinating and decision-making body in the HIV/AIDS response in this country. Through external donor funding, the GAC has increasingly engaged CSOs including NGOs, FBOs and CBOs as co-implementers. As of 2009, the GAC has been working with approximately 30 large international and national CSOs, considered to have better organizational and technical capacity in terms of funding, management and program/project personnel that serve as intermediaries, providing funding and capacity building for smaller CSOs, believed to have limited funding and technical skills for implementing district-wide HIV prevention projects country-wide.The challenge for the GAC is how to effectively harness the role of CSOs in the fight against the national HIV/AIDS epidemic amidst severe fiscal constraints . HoweverIn order to analyze the partnership between the GAC as a state institution and CSOs, it is important to define three terms within the institutional context of the HIV/AIDS response in Ghana. What is meant by the terms "state," "civil society organization," and "partnership?"For the purposes of this study, the following definitions of the terms are used to understand state-civil interactions in the national response to HIV/AIDS.The term state can be used to describe government institutions whose aim is to create and maintain public order and deliver public goods and services. State organizations include the various levels of government: bureaucracies organized often as departments or ministries; state appointed bodies and agencies that provide public services at the national and sub-national or local levels . In thisThe term civil society organization is not understood in the same way globally. A useful definition of civil society that was adopted in the present study is "that sphere of social interaction between the household and the state, which is manifest in norms of community co-operation, structures of voluntary association, and networks of public communication" . CSOs inFinally, a review of the published research and theoretical literature on collaboration revealed that there is no single definition of a partnership; instead, a plethora of terms have been used. Some theorists focus on strategic alliances , action To the knowledge of the researchers, this study is the first of its kind to demonstrate the growing movement towards state collaboration with CSOs to achieve wider national health goals in the HIV/AIDS response. The aim of this study was to provide an investigation of the origins and drivers of such partnerships, the nature and processes of their collaboration, and the barriers and facilitators to achieving successful partnerships. The key research questions that were qualitatively explored are as follows: (1) how do state-CSO partnerships for HIV/AIDS emerge? (2) what are their distinguishing characteristic features? and (3) what successes or challenges do partners' perceive to be associated with partnerships?A qualitative methodology , 29, buiGhana is located in West Africa. It borders Cote d'Ivoire to the west, Burkina Faso to the north, Togo to the east and the Gulf of Guinea to the south. It was the first African country south of the Sahara to gain independence from British colonial rule in 1957. After decades of military rule, Ghana made a transition to democratic rule in 1992 and remains one of the few functioning multi-party parliamentary democracies in the highly unstable West-African sub-region. Economically, it has built reputation as a stable liberal economy and was deemed to have attained a lower middle income country status in 2010.In this study, a random sampling procedure that would require having a complete list of all the partnerships in the country from which samples could be drawn was not used because such a list does not presently exist. Hence, it was purposefully determined that identified organizational partnerships should at least be representative of all the three major geographical zones in the country ― the Northern, the Middle and Southern zones, which reflect Ghana's ethnic and cultural diversity and inequalities in the distribution and access to health care, with the Northern zone and rural areas being the most deprived regarding access to existing health resources . InitialTwo major methods were utilized and triangulated to gather data – semi-structured, in-depth qualitative interviews  and the three geographical zones  in which they are located.Evidence gathered from organizational documents and participants in this study revealed that the first major driver for the involvement of CSOs was the establishment of the GAC by the Parliamentary Act 613 in 2002 to coordinate the country’s HIV/AIDS response. Subsequently, CSOs’ engagement was to be shaped significantly by the availability of the Ghana AIDS Response Fund (GARFUND) of $28.7 million (2002–2005) from the World Bank to support HIV programs of the GAC. Among others, the fund aimed to: (i) support the GAC to implement a multi-sector response; (ii) expand the Ministry of Health’s role to engage CSOs; and (iii) finance eligible activities conducted by CSOs and state institutions to promote a rapid scaling-up of the HIV/AIDS response country-wide .The GAC has since been working with CSOs, guided by specific implementation guidelines, and 5-year national HIV/AIDS strategic frameworks/plans with the wider objective of fighting the HIV/AIDS epidemic through treatment, prevention, care and support interventions , 32, 33.In response to these new demands, the GAC had to reconsider how it worked with CSOs. This meant that CSOs had to be funded to implement projects through the development and submission of competitive project proposals in prioritized areas for review and selection by a Proposal Review and Appraisal Committee. From the GAC’s perspective, this would reduce the number of NGOs it had to coordinate and make its Monitoring and Evaluation (M&E) work more cost-effective ."…You know, the GAC cannot move from their office to be doing HIV work in the districts and communities. So they work with people like us and other smaller NGOs to get their work done across Ghana…it will be a monitoring nightmare for GAC to try and work with all these small NGOs, trying to reach people…So we help them to achieve their objectives. Without organizations like ours, I do not think they can do their work."Another purpose of this new strategy has been to channel funds through large CSOs with better organizational and technical capacity for subsequent disbursement to smaller CSOs, such as NGOs, FBOs and CBOs with limited organizational capacities. The large CSO recipients then become responsible for building the capacity of the small CSOs, monitoring and evaluating their activities, making sure their projects get completed and ultimately furnishing the GAC with standardized data about their work. In complementing this view, one of the large CSO participants in the Southern zone stated:"Before you are taken on board as a SR, you need to provide certain documentation. So they came to do a critical assessment of our financial management system, the staff available, their capacity, years of experience, track record…And for us, we were looking to them being able to support us, give us the requisite technical assistance/support, the funding that we need, and basically, that is what we want."In recruiting small CSOs as co-implementers, the large CSOs use various criteria including their need to possess office space, ancillary staff, strong grassroots presence and linkages with existing government health facilities whose professional input will be required to conduct HIV Testing and Counseling (HTC) programs. Concerning this, one of the study participants from a small NGO in the Southern zone described the process by which small CSOs are recruited as follows:"Because they [large CSOs] are closer to the powers that pay, like the GAC, they can easily get funding. But for us, it is difficult as they do not deal directly with small CBOs. So it is good that we have relations with them.A small CBO participant from the Middle zone captured the nature of the funding relationship between the large and small CSOs and how this benefits the latter as follows:Subsequently, following the initial funding of the GAC by the World Bank, CSOs have been supported by multi-lateral and bilateral donor agencies such as: United States Agency for International Development (USAID); Department for International Development of the United Kingdom (DFID); Danish International Development Agency (DANIDA); and Global Fund to Fight AIDS, Tuberculosis and Malaria ."We were already doing some programs in HIV/AIDS and sexual and reproductive health but we were doing that with small funding from different charities engaging in small initiatives in just some two or three communities across the region. So when we saw the advert, we realized that it was an opportunity for us to expand our services to vulnerable groups in our communities with the additional resources coming from GAC, and so we decided to put in an application. That is how come we became involved with the GAC."Most of the CSOs included in this study were already engaged in some sexual/reproductive health, HIV/AIDS and other health initiatives, but with limited funding from other international NGOs and charities abroad. Consequently, the funding opportunities provided by the GAC were viewed not only as a means by which they could expand their work to various vulnerable groups, such as youth, orphans, women, and people living with HIV (PLHIV) but also, a means by which they could tap into the knowledge and skills provided by GAC through its capacity building initiatives to enhance their work. On this point, one of the large NGO participants in the Northern zone indicated that:Thus, external donor support has been crucial for the engagement of CSOs, and highlights the key role of the GAC through which funds have been channeled to legitimatize the work of CSOs to implement the national HIV/AIDS response.The evidence gathered for this study revealed that the GAC currently maintains a complex relationship with different types of CSOs at three major levels – national, regional and local/district in the response to HIV/AIDS Fig. . At the At the regional level, the CSOs include branches of national NGO networks/coalitions (interest groups) such as NAP+, and regionally-based interest groups of networks/coalitions; local NGOs that either constitutes branches of International NGOs (INGOs) registered as local organizations or indigenous organizations that have been established with assistance from INGOs. At this level, most of the NGOs are described as "medium-sized" NGOs (MNGOs) and their activities are funded by INGOs or other external donor organizations. Some MNGOs provide services directly to community members at this level, while others provide services through small NGOs, FBOs, and CBOs that operate at the local/district levels ."Currently, we are trying to minimize infection or eradicate it, if we cannot eradicate it, educate those who are infected to go for drugs that will help them to live longer…we are also educating them to reduce stigma…and to get everybody to know that AIDS is real!"One participant from a small FBO in the Middle zone described their mutual roles and contributions to the collaboration as follows:In their role as current or previous collaborators of the GAC, CSOs undertake several interventions to reach the general population and "Most-At-Risk Populations" (MARPs): identified as female sex workers, men having sex with men, prisoners, and people who inject drugs. These include community outreach , community mobilization for HTC, condom promotion and distribution, film shows and community drama, distribution of information, education and communication materials, and psychosocial support for PLHIV, as well as home-based care and behavior change counseling ."Because we act as an intermediary between GAC and our partners [CBOs] in the communities, we strengthen that relationship not only by transferring funds to them but we also provide training and pass on skills, not just those that the GAC provides but what we ourselves as an organization have…For instance, they may have problems developing skills in M&E, budgeting, computer applications, and fundraising…the M&E forms they are supposed to fill are very difficult to complete…so we help them…we sometimes join them in their field activities, such as HTC and peer education."Moreover, many participants viewed periodic review meetings organized by the GAC in which implementers do peer reviews of each other’s performance as an important platform for information exchange that helps to build the capacity of CSOs to deliver more effective programming. Additional capacity building initiatives of the GAC include training of implementers on data collection, M&E and peer education techniques and financial reporting and fiduciary issues, using manuals developed by the GAC. Similarly, a large NGO participant from the Northern zone described how the large CSOs help in building the capacity of small CSOs as follows:"We actually deliver the results, so every quarter; we are supposed to report on what we have actually done. And then there is a monthly review meeting we attend to give presentations and assess what we have done. They give us targets…Apart from providing them with personnel and the results; we give them information that would help improve the program. I think they rely a lot on feedback from us because they are not working in the communities or in the field as we do."Additionally, a different participant from a small NGO in the Southern zone described the contribution of small NGOs to the partnership more generally as follows:Thus, while the CSOs actually delivered the services, the contribution of the GAC to the partnership has been to coordinate funding from outside donors to build the capacity of the CSOs and to train CSOs to deliver care and prevention more effectively."We have reporting templates that we use. So, if for example, we are going to do HTC, we have forms that we use to register people’s details…So they are able to track what we do. They give us the targets. For example, in a year we are supposed to distribute about 200,000 condoms. So you can decide to do the distribution over four quarters…And then at the end of each quarter you show how many you have been able to distribute. That will be your results as against the target set…We do thorough reviews, and at these review meetings, every SR, presents their results and everybody sees it."In order to ensure that its programs are effectively and efficiently coordinated the GAC is organized into a "Projects and Technical" division, an M&E unit, and a finance section. Hence, once a contract is signed with a CSO, clear reporting mechanisms with pre-defined performance targets/indicators are used to evaluate progress. Accordingly, one of the participants from a small FBO in the Southern zone described how their performance is tracked by the GAC as follows:"The contract basically spells out what we are supposed to be doing, how much we are supposed to be getting, what you do to get your contract taken off us as a SR…So I can say that it is managed by both parties. For instance, we hold review meetings during the implementation stages; they come around on supervisory visits…And during our review meetings we have a session where there is actual feedback…we see whether there are any gaps, whether there are problems, whether there is the need to change anything…"In disbursing funds to the CSOs, a format is usually applied to determine how much they should maintain for themselves, supervision and various budget lines. The results of their implementation activities are collated into a database and used to generate half-yearly and annual reports for dissemination to key stakeholders, including external donors in order to evaluate progress on goals and objectives. Thus, one of the participants from a small NGO in the Southern zone described how the partnership was managed more generally in the following way:To sum up, the GAC has well-defined administrative structures, procedures and reporting requirements for evaluating the performance of CSOs."By joining this relationship, we have not only gotten funding but also a lot of information, knowledge, materials, M&E skills that have helped to build our capacity to design and implement high quality HIV/AIDS-related activities…Besides, because we work with the GAC as a state agency, it raises the profile and credibility of our organization such that most donors feel safe funding us."Concerning the wider successes of the GAC-CSO partnerships, one of the GAC participants underscored how CSOs had over time become good performers in helping to bring the HIV/AIDS epidemic under control through the capacity-building programs of the GAC and funding from external donors. Similarly, one small CSO participant from the Middle zone expressed how beneficial the partnership has been to CSOs and the credibility the relationship enables them to procure:"Without the funding from the GAC, we would not have been able scale-up our HTC services…we used to do that on a small scale and few people knew their status. But now we have close working relationships with the district assemblies, and the health facilities are more comfortable working with us…So for me HTC is one aspect that we have made achievements…and also condom distribution. For instance, we bought about 700 packets of condoms, but currently we have only a few left…the patronage is encouraging. So it means we are making an impact."Moreover, most of the CSOs suggested that by working together they have been able to reach larger segments of the population with HIV treatment and prevention messages than if they were working independently. Regarding this, one of the participants from a small CBO in the Southern zone explained:Thus, external donor funding made available through the GAC, opportunities for building the capacity of CSOs and their distinctive strengths in mobilizing and inducing action on the part of the communities to positively respond to the national HIV/AIDS epidemic are considered success factors of their relationships."The fact is, because it’s basically donor funding that we are relying on, once the expected funding does not come in or delay, everything comes to a halt. During the last project they were supposed to, by the terms of the contract give about GH¢80,000…and the first installment of 50 % was paid in line with the agreement…the second installment of 50 %, which is GH¢40,000 was supposed to be paid but it was delayed for over four months and they ended up paying only GH¢20,000 towards the end of the project."First, a majority of the CSOs attested to delays in the release of funds and tendency of the GAC to reduce initially agreed upon funds in the contract agreement as one of the critical challenges that impacts their work. Regarding this, a large NGO participant from the Northern zone responded by stating:"What has been a challenge sometimes when it comes to working with government partners has to do with the bureaucracies in terms of delivery or disbursement of funds to organizations to work with and the hierarchies that we have to go through in accessing funds."Concerning this, a different participant from a large NGO in the Southern zone expressed worry about the bureaucracy associated with accessing funds from the GAC as follows:Second, several of the CSOs also expressed dissatisfaction with the tendency for the GAC to make grants on an annual basis instead of having the grants as multi-year commitments. Annual grants were found to adversely affect not only the sustainability of their programs, but also, their survival as organizations. Instead, the CSOs proposed that, having multi-year grants that last between two and five years will enable them to make long-term commitments to resources and staff and to invest in long-range targeting and planning to more effectively and efficiently respond to the national HIV/AIDS epidemic.At the same time, participants from the GAC emphasized that their financial support from key development partners, such as the USAID, DANIDA, DFID and Global Fund has been declining in recent years, which is blamed on the current global financial crisis and fears that this could negatively impact their response to the national HIV/AIDS pandemic. They also indicated that increased governmental funding is critical if efforts to date are to be sustained and have a long-lasting positive effect.Apart from issues of funding, most of the small CSO participants noted the tendency for the GAC to set unrealistic targets for HTC activities and condom distribution, as major obstacles to their performance. For HTC activities, set targets were often hard to meet due to limited supplies of HIV testing kits from the GHS, which due to shortages, often restricted HTC to essential activities, such as testing pregnant women and ensuring blood safety. In other situations, the kits may be available but the stringent bureaucratic processes CSOs have to go through to obtain the kits can be frustrating. As a result, the effort, time and money invested in the peer educators who normally mobilize and counsel community members for HTC are compromised. This tends to undermine the whole idea of helping people to know their HIV status as a key ingredient to encouraging people to make informed choices in the fight against HIV/AIDS. Concerning condom distribution, set targets could often not be met, due to a recent directive from the GAC to sell the condoms, which were being distributed free of charge. This had resulted in huge stocks of the commodity remaining unsold. As a result, the CSOs suggested the need for the GAC to revisit its stance on the sale of condoms to increase access to them as a vital commodity for preventing and/or reducing new HIV infections country-wide."…the main problem is the referrals, because we go to the schools to do HTC with GHS personnel…we get reactive cases but they keep the records to themselves…so if we don’t follow-up on the cases then nothing gets done. So, most at times, we test the people and they show positive…but they are left alone and not taken care because of a poor referral system."Several participants also reported instances where reactive cases from HTC programs were not linked to care and treatment by health personnel in certain districts as a major challenge to HIV treatment and prevention efforts, such as highlighted in the following quote from a small NGO in the Southern zone:"…they [GAC] need to re-look at the partnership agreement and involve us from the onset in defining clearly what our role and theirs is going to be…Because what is happening now is that we do not make any inputs or negotiate on the terms of the contract. They have a standard agreement for everybody to just sign. So we tend to have many challenges before the program ends."Moreover, some of the participants complained about non-participation of CSOs in the negotiation of the terms and conditions of their contract and the tendency for the GAC to simply impose the contract on them as unfair. Most participants indicated that they would prefer to have the terms and conditions of the contract negotiated and agreed upon before the two parties' sign, such as what is reflected in the following statement by a large NGO in the Northern zone:"We train people and all of a sudden they are gone and we have to train new people again…these trainings cost money, so if you have to be repeating this over and over again… the ability to gain and keep the experience becomes a problem and our coordination efforts suffer…"On another note, one GAC participant from the Southern zone stressed the high staff turnover rate among the CSOs as a serious problem of the collaboration in the following way:Thus, funding issues and other structural barriers constitute key influences on the adverse performance of the partnerships.This article has provided an overview of on-going state-civil society partnerships for HIV prevention and treatment in Ghana. Major findings include that the commitment by government and CSOs to work in collaboration with external donors to implement decentralized organizational structures and specific administrative policies and practices allow for more successful performance and sustainable involvement in responding to the HIV/AIDS pandemic in Ghana. In particular, this study attests to how this can be done by implementing guiding principles and modes of operation that result in increased access to resources and improved service provision that no one party working alone would have achieved. This inherently increases the efficiency and effectiveness of state-civil society partnerships overall, and implies that the original goals of the GAC to embark upon CSOs’ involvement in the national HIV/AIDS response are being met.The involvement of CSOs has been found to be valuable in many ways. These includetheir role in: 1) delivering more cost-effective HIV/AIDS services through their community mobilization, capacity building, information, resources and skills exchange; 2) complementing and extending the delivery of public sector services, including the provision of more comprehensive HIV/AIDS services that suit local needs and challenges; 3) increasing community mobilization for the HIV/AIDS response, with improved M&E and accountability through the adoption of results-based mechanisms-essential for proper coverage and use of allocated resources; 4) promoting positive behavior change and enhanced prevention through community outreach , use of film shows and community drama; 5) improving communication networks through international, national, regional and local/district CSO linkages, capacity building, information exchange and sharing lessons for more effective HIV/AIDS programming; and 6) promoting representation of the perspectives of CSOs , including those of vulnerable groups and underserved communities  in national HIV/AIDS policies and programs.With the increasing involvement of CSOs by the GAC, new organizational arrangements are emerging to execute the national HIV/AIDS response. However, the early history of these partnerships prevents this study from drawing any final conclusions on the impact of CSOs’ involvement in the national response to the HIV/AIDS epidemic. Nonetheless, it is possible to delineate at least one major model of the GAC’s successful engagement of CSOs that can be replicated in other settings. This model is one in which the GAC operating with donations disburses funds to few CSOs with larger absorptive capacity who act as intermediaries distributing funds to a larger number of smaller, less equipped NGOs, FBOs and CBOs to execute the country’s HIV/AIDS strategy at the national, regional, district and community levels. Investing and promoting the adoption of this model in other settings might be useful as the search for the most appropriate methods for combating the global HIV/AIDS pandemic continues.This study also draws attention to significant challenges to effective partnerships, which can be seen as structural: they are linked to the ways in which the GAC and CSOs manage and organize their affairs in the collaboration, and to current trends affecting the national HIV/AIDS response. These include, high NGO staff turnover rate; shortage of HIV testing kits, unrealistic targets set for HTC and condom distribution; the non-participation of CSOs in the negotiation of the terms and conditions of their contractual agreements, failure to link reactive HIV cases to care and treatment; dwindling external donor funding; short funding duration; delays and problems associated with the aid chain: how funding conditions (i.e. documentation requirements and bureaucratic procedures) shape the movement of aid through the GAC to CSOs for work in the national HIV/AIDS response. Arguably, most of these obstacles can be addressed through targeted new polices, mechanisms and tools, moving forward to more effectively and efficiently engage CSOs in addressing the HIV/AIDS epidemic.This study has limitations. Namely, the study was conducted in only one developing country – Ghana. Future research should increase the scope of the study in other developing countries to provide a more comprehensive picture of on-going state-civil society relations in response to the global HIV/AIDS pandemic in order to establish the universality of this study's findings for replication in other settings. This study underscores successes and challenges to date that are associated with state-civil society relations in the fight against the national HIV/AIDS epidemic; longitudinal research is needed to study the influence of suggested changes on state-civil society partnerships in Ghana.Based upon the findings of this study, conclusions include that attention needs to be paid to the major barriers to funding identified by the GAC and CSOs such as, scarcity and reductions in allotted money, delays in disbursement, and short funding duration for more successful performance of the partnerships. Incidentally, both the GAC and CSOs were in agreement that realizing the full benefits of these partnerships is not simply a matter of providing funding and setting up organizational systems supporting these partnerships. External donors and government in close consultation with CSOs have an important role to play in altering the environment of the "aid chain”: complex application processes and administrative and reporting requirements that shape the free flow of funds to local CSOs and to put in place new rules, procedures and strategies that overcome these barriers. Finally, the GAC and CSOs recognize that the channeling of multilateral, bilateral donor funding through state institutions established to execute national HIV/AIDS responses to local CSOs in developing countries remain a critical challenge. Hence, they recommend sharing of information and best practices on how to successfully engage local NGOs among external donors, governments, CSOs and other HIV/AIDS implementers, as a means of overcoming the challenge.CBOs, Community-based organizations; CSOs, Civil society organizations; DANIDA, Danish international development agency; DFID, Department for international development of the United Kingdom; FBOs, Faith-based organizations; GAC, Ghana AIDS commission; GHS, Ghana health service; Global Fund, Global fund to fight AIDS, tuberculosis and malaria; HIV/AIDS, Human immunodeficiency virus/acquired immune deficiency syndrome; HTC, HIV testing and counseling; INGOs, International NGOs; M&E, Monitoring and evaluation; MARPs, Most-at- risk populations; MNGOs, medium-sized NGOs; NAP+, Ghana network of persons living with HIV/AIDS; NGOs, Non-governmental organizations; PLHIV, People living with HIV; SR, Sub-recipients; USAID, United States agency for international development


Antibiotic resistance is a serious global public health problem directly correlated to high antibiotic consumption. Romania is one of the European countries with the highest rates of antibiotic consumption, non-prescription antibiotics use and resistance of several pathogens to antibiotics. Pharmacists are an important stakeholder in respect to antibiotic management and context specific research on this topic is needed.The aim of the research is to increase the understanding of how community pharmacists in Romania perceive their roles in respect to antibiotic consumption and antibiotic resistance.Semi-structured interviews with 18 pharmacists were conducted to explore the perceptions and attitudes of pharmacists towards their roles on antibiotics consumption and antibiotic resistance. Manifest and latent qualitative content analysis was used to analyse interview transcripts.Maintaining equilibrium between ethics, law and economy’ expresses how pharmacists often feel when trying to fulfil their duties considering all the dimensions of the pharmacist profession.‘ Antibiotic resistance problem rooted in a low social capital environment’ reflects the pharmacists’ perceptions of the deep causes of antibiotic resistance and the underlying problems that perpetuate the status quo and impact their role in relation to this problem. Wanting to fulfil their educational role illustrates how the pharmacists feel they could best contribute to improving the present situation. The overarching theme ‘Undervalued medicines’ professionals struggling with agency related and structural barriers to meet their deontological duties’- meaning the ethical responsibilities that come with the pharmacy practice, reflects that the pharmacists see their roles as being challenged by several barriers.Three sub-themes emerged from the analysis. ‘A health system and societal context perspective is helpful in order to understand the pharmacists’ roles in respect to antibiotic consumption and antibiotic resistance. Health promotion interventions and policy revisions should take into account concepts of structure and agency. These could highlight barriers that pharmacists encounter in their activities related to antibiotics management. Antibiotic resistance is a serious global health problem and there is wide consensus that the major cause of antibiotic resistance development is use of antibiotics . The WHOOther determinants of antibiotic dispensing without a medical prescription are external responsibility and indifference, as pharmacists could tend to transfer responsibility to other actors such as other pharmacists/medical staff, patients, the healthcare system or the use of antibiotics in animals .Financial considerations also alter the pharmacists’ behavior in respect to dispensing of antibiotics  but theyStaphylococcus aureus (MRSA), multidrug-resistant Klebsiella pneumoniae  and vancomycin resistant Enterococcus faecium  Accessibility to the family doctor is truly hard, very difficult.[P9]financial barriers to taking antibiotics correctly. This sub-category differentiates itself from the first as it expresses the pharmacists’ impressions on the patient’s predicament in sustaining a correct medical treatment. Another sub-category that was formed was a result of perceptions on the social situations that affect vulnerable populations. Pharmacists’ attitudes towards these population groups highlight the ethical dilemmas they face when patients ask for antibiotics without a medical prescription. The pharmacists describe the situation of uninsured people resulting from unemployment, a situation often faced by the Roma minority, or emigration. Pharmacists described a situation where Romanians go abroad to work, usually in low paying jobs with limited benefits, either in agriculture or construction. Before they leave, or when they come home for their annual leave to visit, they try to buy medicine in Romania to have them, if they need them, in their new country of residence, as they are often not covered by insurance there either.There are some patients that go abroad you know. There, they really don’t have access to the doctor. These patients ask for antibiotics, to have it there for the worst. At least in XXX, there are a lot that are away, so there is also this situation.[P9]Furthermore pharmacists expressed how they see also the patient’s health comes first and therefore the professional behavior needs to be aligned to these considerations.In particular most of the patients that solicit medicines without prescription are the dentists’ patients and this is because I am speaking for XXX where the problem is that there is no on-call service for dental problems […] But you can’t go home in peace knowing that that person has a night in front of him, because even if they go to the emergency room, there, they are told that the case doesn’t belong to them [the hospital], so they can’t help him.[P14]Noticing these health system barriers that patients face, the pharmacists consider that facing negative incentives that determine a pharmacist to push the limits of law. This supports the dichotomous perspective on the pharmacist profession: a medical formation operating in a business environment. The interviewees talked about the impact on the pharmacist’s behavior of the distributors’ discounts for antibiotics as well as the unhealthy competition triggered by the numerous pharmacies.…in Romania these things, they are … borderline. Because if you don’t do something, you don’t make it so, you need to maintain a sort of morality and at the same time keep your business …it’s sort of difficult. [P3]The participants also expressed their predicament when Sub-theme 2: Antibiotic resistance problem rooted in a low social capital environment reflects the pharmacists’ perceptions of the underlying causes of antibiotic resistance and impact their role in respect to this problem. The following categories formed this sub-theme: (1) distrust in state institutions, (2) suffering from an image deficit at all levels including among themselves, (3) high rates of antibiotic consumption and antibiotic resistance as a collective fault for a neglected but serious issue and (4) working in silos.Distrust in state institutions signals low vertical social capital. The pharmacists consider the current legislation that allows the dispensing of antibiotics only with prescription -except for emergency situations, as a flawed law that is often bent or broken. The participants expressed feelings of unfairness as it would allow for unjust power asymmetries and unfair repercussions.the Ministry of Public Health as a challenged institution.so I don’t see, I don’t know how to say it… the infrastructure, they don’t have personnel for these inspections, they don’t have people that can go and check what’s really happening,..[P6]The pharmacists revealed distrust towards the state’s capacity to carry out their control roles. Under-staffing of these institutions, suspicion of corruption and lack of understanding of the situation on the ground were mentioned by the participants forming an image of a strained relationship between the state and the pharmacists and often felt counted out from decision making.The interviewees perceived unreliable statistics, as the method of gathering data is perceived unreliable due to unlikely admission of acts of transgression by the pharmacists who provide the data.I’m not interested in this, I mean the magnitude of the phenomenon cannot be measured, because no pharmacy will admit that they give without prescription as long as it’s outside the law and you can’t have a proper statistics … [P16]Some pharmacists suspect pharmacists –theoretical roles that are not translated into practice illustrates how pharmacists view the theoretical possibilities for the profession and the realities of every-day practice. The participants have highlighted their dissatisfaction with the non-applicability of the role of clinical pharmacy in practice, signaling a lack of trust in the existing structures’ way of operating as well as the professional networks.I wish to see the day when the pharmacist will be the one who is asked in the hospital what antibiotic should be used, not which one is the cheapest one, who owns the license… [P14]The sub-category suffering from an image deficit at all levels including among themselves. Every participant mentioned they felt that in some cases the pharmacist is perceived as a salesperson.In general at this hour, the patients see the pharmacist as a medicine salesperson because this is what the profession has been reduced to. [P18]Thinking about the experiences of dispensing antibiotics, the interviewees reflected on the existing perceptions on the profession indicating that they are pharmacist assistant – sometimes used to the detriment of the medical act also contributed to the pharmacist’s image deficit. Participants revealed situations when the pharmacist assistant is dispensing antibiotics without prescription and is less likely to consider the associated risks in the face of pressure from the owner of the pharmacy.The pharmacists’ university education as questionable. The newly established institutions are perceived as having less educational rigor. This points towards an intra-professional image deficit and a weak horizontal social capital.The respondents’ attitudes towards their peers’ education illustrated that some view pharmacists’ continuing education rarely targets antibiotics and mostly focuses on the commercial aspects of the profession. This also fuels the image deficit as it degrades the role of a pharmacist and the trust pharmacists place among their peers and educators.But it would be very good and highly recommended for these courses, that are taken to get professional points, to be on antibiotic themes, because the great majority now are about pharmacy marketing, how to associate various products –OTCs, para-pharmaceuticals, etc. Meaning a lot of companies and producers, even generics, are looking to make courses pertaining to marketing and sales…[P8]In line with the intra-professional image deficit the pharmacists also expressed that The high rates of antibiotic consumption and antibiotic resistance - a collective fault for a neglected but serious issue signals the perceptions of pharmacists in respect to the status quo of these problems. Antibiotic resistance, a low-visibility problem, was seen by every participant as a serious one that is not tackled sufficiently. Pharmacists, doctors, the uneducated public that not only consumes but also may dispose of unused antibiotics in an inappropriate manner, consumption for animal husbandry, state structures that should exercise control, are points that have mentioned and formed the idea that high antibiotic consumption is a shared blame.It’s hard to answer, but some maybe think we give out too easily the medicines, but they are also responsible to the same extent because they prescribe in the same way. There are a lot of prescriptions and now with these colds they come still with antibiotics. [P4]working in silos and signaled a limited or degraded institutional collaboration with the doctors. The institutional norms of reciprocity are also questioned, as participants recalled cases when a legitimate professional concern met an arrogant, dismissive attitude from the doctors.When thinking about the collaboration with the doctors, the interviewees highlighted that currently professionals are distrust in the doctors’ resources to carry out a good quality medical act. This is a result of knowing the limited resources the doctors have in respect to performing bacterial culture and antibiotic susceptibility testing and the brief time dedicated to conducting a detailed anamnesis. The participants also perceived that patients sometimes have a diminished respect for the doctors as they are being recommended the same antibiotics each time. All these suggest a breakdown in the traditional patient- medical professional relationship, built on trust.Furthermore the collaboration is strained by pharmacists’ Sub-theme 3 Wanting to fulfil their educational role emerged as a concept that illustrates how the pharmacists feel they could best contribute to improving the present situation. The interviewees expressed repeatedly their concerns in relation to the (1) need for education and the (2) pharmacists potential to educate.patients have an incorrect conduct in pharmacies when it comes to antibiotics. A combination of factors can lead to the patient’s inappropriate reactions when being turned down. However lack of education in general and in respect to the pharmacist’s role was always mentioned as the underlying cause in such situations.Often participants signaled that questionable sources of getting medical information by both professionals and patients. The family remains the main source of shaping sanitary behavior. Many participants suggested patient education in the form of formal school hygiene education programmes as a sustainable solution to the information deficit.If you made a patient understand this thing, you made another 10 understand, because he is young, in his turn he will have children, his children will learn this, the wife and so on… This education is being transmitted from generation to generation and I consider that we must start doing this and do our job! [P6]Participants also pointed towards pharmacists’ potential to educate was mentioned not only as a duty but also as facilitated by the pharmacy itself as it is perceived as an accessible and welcoming environment. The interviewees suggested that the less pronounced power asymmetry between the patient and the pharmacist, in contrast with the patient-doctor one, is a result of the patient paying at the pharmacy, therefore feeling more relaxed and confident in having a discussion with the professional.The Pharmacists also identified as being a voice in the community. They expressed their satisfaction with being appreciated and thanked for their recommendations. Often an air of nostalgia was perceived during the interviews with the older pharmacists, as they expressed how the pharmacist’s standing in their communities was in the past and how, now, it has diminished.The overarching theme ‘Undervalued medicines’ professionals are struggling with agency related and structural barriers to meet their deontological duties’ speaks to all the identified sub-themes. Maintaining equilibrium between ethics, law and economy first pointed to the struggle of meeting the deontological duties- meaning the ethical responsibilities that come with the pharmacy practice. The need to follow the law, considering the health system structures is a challenge when thinking of moral agency. The sub-theme hints of the question of value as medicine professionals are being forced to respond to market incentives. The antibiotic resistance problem rooted in a low social capital environment sub-theme revealed other layers of complexity of the antibiotic consumption and antibiotic resistance phenomenon for pharmacists. The structural dimensions of vertical trust- trust in authorities, were accompanied by the horizontal social capital issues – trust between individuals and networks. The aspect of wanting to fulfil their educational role also captures the issues of value of the pharmacist’s education and ability to educate, the agency discussion in respect to the capacity of the pharmacist to act and the structural component of the how education is being provided.‘Undervalued medicines’ professionals struggling with agency related and structural barriers to meet their deontological duties’ when it comes to antibiotic dispensing and antibiotic resistance.The overarching theme suggests that the pharmacists see themselves as The first sub-theme interprets the ethical dilemmas pharmacists encounter in trying to fulfil their professional role. This research brings forth the challenges pharmacists face when they see how the health system impacts the patient’s ability to seek care. Considering antibiotic resistance from a health system perspective implies understanding the interdependencies within and between systems . The negthe social resources that evolve in accessible social networks or social structures characterized by mutual trust”. This places social networks, social trust and social resources as components of social capital. Social trust influences health in two ways. Social capital can have a compositional effect on health as trust may influence directly individual health, but also a contextual effect as social trust impacts the political and social environment, the welfare regime and therefore indirectly health. When discussing the type of social capital the literature offers different classifications. Thinking about the structural dimension, the concepts of bonding, bridging and linking capital are employed [The second sub-theme explores how pharmacists perceive the impact of elements that form social capital on their role as professionals in handling antibiotics and preventing antibiotic resistance. Starting from the considerations on the conceptual vagueness of social capital, Rostila  proposesemployed . BondingResearch indicates that post-socialist, Eastern European states, such as Romania, have a low bridging and linking social capital , 32. FinThe perceptions in respect to the educational role the pharmacists can, and want, to play were considered also in connection to the patient’s level of medical knowledge are supported by previous research , 3, 5.The overarching theme reflects the three sub-themes by employing the concepts structure and agency. Previous analysis discusses the potential of social theories that would involve these concepts in respect to promoting medication adherence  and suggstructure as “the recurring patterns of social interaction through which people are related to each other, such as social institutions and social groups” while agency is “the ability of people, individually and collectively, to influence their own lives and the society in which they live.” The combination of levels of intensity of either structure or agency results in various theories, as they consider whether social structures or human agency decide an individual’s behavior.Germov  defines We consider that agency and structure are concepts that should be further explored in respect to the pharmacists and the stakeholders that impact their activity, as the power asymmetries that exist have a decisive impact on how the pharmacists view their role. The sub-themes highlight the agency problems linked to low bridging capital as well as the structural barriers that spring from the linking social capital. The ethical dilemmas could be a results of a combination of agency and structural factors and the same applies to the discussion on the educational aspects where a pharmacist’s agency to educate comes through chiefly. Therefore we suggest further research with a closer lens on social theories of agency and structure and concentrating on the symbolic interactions at pharmacist-patient and pharmacist-doctor level.Considerations on ensuring trustworthiness in this qualitative research have been taken ever since the planning stage. The criteria that were considered to ensure trustworthiness were: credibility, transferability, dependability, and confirmability . CredibiTransferability concerns the applicability of the findings to other situations . It was Dependability means that if study were to be repeated, in the same manner, it would produce similar results . DependaConfirmability pertains to data neutrality . The intConsidering the above mentioned strengths and limitations the study is thought to have a good degree of trustworthiness.Antibiotic resistance is a serious global public health problem and it is directly correlated to high antibiotic consumption. Romania is one of the European countries with the highest rates of antibiotic consumption, non-prescription antibiotics use and resistance of several pathogens to antibiotics.Pharmacists are an important stakeholder in respect to antibiotic management and therefore context specific research on this topic was found adequate. The study sought to increase the understanding of how community pharmacists in Romania perceive their roles in respect to antibiotic consumption and antibiotic resistance. The research indicates that pharmacists see themselves as being undervalued health professionals, that when trying to meet their deontological duties face several agency related and structural barriers. This confirms the need to consider antibiotic resistance in a health system and societal context and design interventions that take into account concepts of structure and agency. More research is needed to understand the structural and agency rapports between all stakeholders. As antibiotic resistance has dire public health and economic consequences, these types of research and interventions would positively impact the current situation in Romania.


Recent studies revealed that the growth yield of high quality singlelayer (SL) MoS2 is essentially controlled by quite a few parameters including the temperature, the pressure, the amount/weight of loaded source precursors, and the cleanup of old precursors. Here, we report a dispersive growth method where a shadow mask is encapsulated on the substrate to ‘indirectly’ supply the source precursors onto the laterally advancing growth front at elevated temperatures. With this method, we have grown large-area (up to millimeters) SL-MoS2 nanosheets with a collective in-plane orientation on c-plane sapphire substrates. Regular ripples (~1 nm in height and ~50 nm in period) have been induced by laser scanning into the SL-MoS2 nanosheets. The MoS2 ripples easily initiate at the grain boundaries and extend along the atomic steps of the substrate. Such laser-induced ripple structures can be fundamental materials for studying their effects, which have been predicted to be significant but hitherto not evidenced, on the electronic, mechanical, and transport properties of SL-MoS2.Vapor-phase growth of large-area two-dimensional (2D) MoS Both the dispersive CVD growth method and the laser-induced rippling may have important consequences in experimental and theoretical studies of SL-MoS2 and other 2D materials.Here, we report an experimental observation for regular ripple structures induced by laser illuminations/scanning into high-quality SL-MoS2 atomic layers grown by CVD on c-plane sapphire substrates using a direct and a dispersive method, respectively. MoO3 and S powders, the same as previous work2 samples. 2 grown by the dispersive and the direct method, respectively. Triangle and hexagonal MoS2 grains  PL emission and exciton resonance absorption peaks  employed in this study.ains see  are alsoeaks see  indicate2 nanosheets in 212 on the c-plane sapphire substrate has a collective in-plane orientation in large-area. The collective in-plane orientation is also evidenced by lowering the dispersive growth temperature from 950 to 750 °C  with a mapping step of 4 μm revealed that the A1g-E2g1 frequency differences of the SL-MoS2 nanosheet are strongly correlated with its PL emission wavelengths  also exhibits a blue shift at the grain boundary. The observed blue shifts in the PL emission and Raman phonons of SL-MoS2 at the grain boundaries are consistent with those reported by van der Zande et al.To verify the laser-induced SL-MoS2 square, having a sharp contrast from its surroundings, induced by the laser illuminations. AFM imaging with a larger magnification at the top edge of the laser illuminated square was further carried out; the phase and height images are shown in 2 nanosheets by the laser illuminations during the slow Raman and PL mappings. The comparisons between 2 ripples arranged themselves along the atomic steps of the c-plane sapphire substrate. A closer look at the images in 2 ripples is much easier at the grain boundaries.2 in 2 on the c-plane sapphire substrate. Another piece of evidence for the conformal growth of 2D-MoS2 nanosheets on c-plane sapphire is shown in 2. Due to the conformal growth, the surface undulation of the as-grown SL-MoS2 is exactly following the surface steps of the c-plane sapphire  at a position away from the grain boundary. Raman, PL and absorbance spectra were collected before and after the laser illuminations from the center area of the 10 × 10 μm2 square. The spectra are shown in 2 are indeed smaller than 0.2 wavenumbers36To study the optical properties of the rippled SL-MoS-) of SL-MoS2392 nanosheets induced by the laser-illuminations tends to suppress the neutral exciton recombination but has only a minor effect on the trion emissions. This emission intensity evolution could be related to the spatially separation of photo-carriers into the peak and valley areas as well as the intermediate surface and/or interface environment changes due to the film rippling2 nanosheets on c-plane sapphire substrates with MoO3 and S powders as the reaction precursors. Comparisons between the direct and the dispersive growths are schematically shown in 2 could occur anywhere on the substrate. The growth is essentially controlled by quite a few parameters. However, with the encapsulation of a shadow mask on the substrate the nucleation of MoS2 can only start at the edge of the masked area . The high growth temperature and the nonexistence of dangling bonds on the grown MoS2 nanosheets tend to promote the surface mobility of the adatoms towards the growing front under the shadow mask, meanwhile, minimize the nucleation of MoS2 on the grown layer. As a result, large-area, continuously, and high quality SL-MoS2 nanosheets are strategically obtained. The SL-MoS2 nanosheets conformally grown on the c-plane substrate, have a collective in-plan orientation, i.e., MoS2[10-10]//Al2O3[11-20]. The boundary area between adjacent SL-MoS2 grains exhibits the same blue-shift behaviors in Raman/PL features as those observed previouslyA dispersive growth method has been introduced in conventional CVD growth of SL-MoSarea see . In this2 nanosheets by laser illuminations. The laser-induced SL-MoS2 rippling, via buckling at the middle of the atomic terraces but pinning at the atomic steps, easily initiates from the grain boundaries and extends along the atomic steps of the substrate. The rippling can be associated with a rearrangement of in-plane strains and the interfacial van der Waals interactions between SL-MoS2 and the c/6-stepped surface of the c-plane sapphire substrate. Such laser-induced ripple structures, absent in multilayer MoS2 nanosheets, only have a minor effect on phonon frequencies and exciton resonance absorption peaks but apparently cause a red shift to the main PL emission peak of the SL-MoS2. However, when the main PL emissions are deconvoluted into two peaks (with a separation of 30 meV), corresponding to those of exciton- and trion-dominated emissions, we found that their peak wavelengths are indeed intact after the laser-induced rippling. The relative intensity changes of the exciton- and trion-dominated PL emissions could be related to spatially separations of photo-carriers into the peak and valley areas of the rippled film as well as the changes of the intermediate surface/interface environment caused by the film rippling2 may have important consequences towards wafer-scale large-area single crystal SL-MoS2.We also demonstrated that regular ripples with the period of 50 nm and the height of 1.0 nm can be introduced into the SL-MoS2 atomic layers were grown by CVD using a method similar to ref. 3 powder  loaded in a crucible was used as the reaction precursors. The sapphire substrate physically encapsulated by a shadow mask , was set in the downstream at a distance of about 8–10 mm from the MoO3 source. The growth was performed at 950 °C for 20 min under atmospheric pressure. Large-area SL-MoS2 nanosheets are obtained on the surface of sapphire under the shadow mask, where the growth is named dispersive growth (ref. indirectly’ exposed to the reaction species.MoS2 ripples simultaneously during the Raman and PL mappings. For the fast Raman and PL mappings (100 × 100 μm2), the step size is 4 μm and the integration time is 2.0 s. After this round of mapping, ripples are seen already in the area of grain boundary (see 2), the step size was reduced to 0.4 μm and the integration time is kept the same . By automatically switching the working mode (controlled by software) between Raman and PL, we are able to collect the typical Raman and PL spectra from exactly the same area of the SL-MoS2 nanosheets before and after the laser illuminations, i.e., without and with the laser-induced ripples.AFM images were recorded using a tapping mode in a Veeco Dimension-Icon AFM system. Confocal micro-Raman/PL measurements were carried out in a Witec alpha 300 system. The experiments were performed at room temperature in a backscattering configuration using the 532-nm line of an argon-ion laser adjusted to ~5.0 mW as the excitation source. This laser is also used as the illumination source for generating the MoSdary see . For theHow to cite this article: Liu, H. and Chi, D. Dispersive growth and laser-induced rippling of large-area singlelayer MoS2 nanosheets by CVD on c-plane sapphire substrate. Sci. Rep.5, 11756; doi: 10.1038/srep11756 (2015).