Air Pollution Exposure Assessment for Epidemiologic Studies of Pregnant Women and Children: Lessons Learned from the Centers for Children’s Environmental Health and Disease Prevention Research

The National Children’s Study is considering a wide spectrum of airborne pollutants that are hypothesized to potentially influence pregnancy outcomes, neurodevelopment, asthma, atopy, immune development, obesity, and pubertal development. In this article we summarize six applicable exposure assessment lessons learned from the Centers for Children’s Environmental Health and Disease Prevention Research that may enhance the National Children’s Study: a) Selecting individual study subjects with a wide range of pollution exposure profiles maximizes spatial-scale exposure contrasts for key pollutants of study interest. b) In studies with large sample sizes, long duration, and diverse outcomes and exposures, exposure assessment efforts should rely on modeling to provide estimates for the entire cohort, supported by subject-derived questionnaire data. c) Assessment of some exposures of interest requires individual measurements of exposures using snapshots of personal and microenvironmental exposures over short periods and/or in selected microenvironments. d) Understanding issues of spatial–temporal correlations of air pollutants, the surrogacy of specific pollutants for components of the complex mixture, and the exposure misclassification inherent in exposure estimates is critical in analysis and interpretation. e) “Usual” temporal, spatial, and physical patterns of activity can be used as modifiers of the exposure/outcome relationships. f) Biomarkers of exposure are useful for evaluation of specific exposures that have multiple routes of exposure. If these lessons are applied, the National Children’s Study offers a unique opportunity to assess the adverse effects of air pollution on interrelated health outcomes during the critical early life period

ActiveRemediation: The Search for Lead Pipes in Flint, Michigan

We detail our ongoing work in Flint, Michigan to detect pipes made of lead and other hazardous metals. After elevated levels of lead were detected in residents' drinking water, followed by an increase in blood lead levels in area children, the state and federal governments directed over $125 million to replace water service lines, the pipes connecting each home to the water system. In the absence of accurate records, and with the high cost of determining buried pipe materials, we put forth a number of predictive and procedural tools to aid in the search and removal of lead infrastructure. Alongside these statistical and machine learning approaches, we describe our interactions with government officials in recommending homes for both inspection and replacement, with a focus on the statistical model that adapts to incoming information. Finally, in light of discussions about increased spending on infrastructure development by the federal government, we explore how our approach generalizes beyond Flint to other municipalities nationwide.Comment: 10 pages, 10 figures, To appear in KDD 2018, For associated promotional video, see https://www.youtube.com/watch?v=YbIn_axYu9

Beyond Antimalarial Stock-outs: Implications of Health Provider Compliance on Out-of-Pocket Expenditure during Care-Seeking for Fever in South East Tanzania.

To better understand how stock-outs of the first line antimalarial, Artemisinin-based Combination Therapy (ACT) and other non-compliant health worker behaviour, influence household expenditures during care-seeking for fever in the Ulanga District in Tanzania. We combined weekly ACT stock data for the period 2009-2011 from six health facilities in the Ulanga District in Tanzania, together with household data from 333 respondents on the cost of fever care-seeking in Ulanga during the same time period to establish how health seeking behaviour and expenditure might vary depending on ACT availability in their nearest health facility. Irrespective of ACT stock-outs, more than half (58%) of respondents sought initial care in the public sector, the remainder seeking care in the private sector where expenditure was higher by 19%. Over half (54%) of respondents who went to the public sector reported incidences of non-compliant behaviour by the attending health worker (e.g. charging those who were eligible for free service or referring patients to the private sector despite ACT stock), which increased household expenditure per fever episode from USD0.14 to USD1.76. ACT stock-outs were considered to be the result of non-compliant behaviour of others in the health system and increased household expenditure by 21%; however we lacked sufficient statistical power to confirm this finding. System design and governance challenges in the Tanzanian health system have resulted in numerous ACT stock-outs and frequent non-compliant public sector health worker behaviour, both of which increase out-of-pocket health expenditure. Interventions are urgently needed to ensure a stable supply of ACT in the public sector and increase health worker accountability

Managing an Epidemic: Zika Interventions and Community Responses in Belize

Implementing effective health interventions in recent epidemics has been difficult due to the potentially global nature of their spread and sociocultural dynamics, raising questions concerning how to develop culturally-appropriate preventive measures, and how these health threats are understood locally. In Belize, health policy makers have only been marginally effective in managing infections and mosquito vectors, and Zika has been declared endemic in multiple regions of the country, particularly on the island of Caye Caulker. With one locally confirmed case of microcephaly on this small island already, this disease has the potential to severely impact the health and wellness of pregnant women and future generations. Based on ethnographic and Geographic Information Systems research conducted primarily in 2017, I examine how perspectives of Zika-related health risk are shaped, and how state interventions to manage Zika are understood. I argue that despite its declared endemic status, Zika is not perceived as a true health concern for community members due to numerous neoliberal structural challenges. Moreover, the state\u27s restrictive form of reproductive governance which limits family planning services is forcing individuals to weigh conflicting conceptions of health consequences. This also contributes to an ambiguous healthcare environment for health practitioners, giving them an unclear picture of the scope of Zika as a public health concern and limiting their ability to treat patients. This thesis also considers how critical medical anthropology and feminist analytical approaches are useful in exploring these questions and contributing to understandings of the health impacts of Zika

Biosignal and context monitoring: Distributed multimedia applications of body area networks in healthcare

We are investigating the use of Body Area Networks (BANs), wearable sensors and wireless communications for measuring, processing, transmission, interpretation and display of biosignals. The goal is to provide telemonitoring and teletreatment services for patients. The remote health professional can view a multimedia display which includes graphical and numerical representation of patients’ biosignals. Addition of feedback-control enables teletreatment services; teletreatment can be delivered to the patient via multiple modalities including tactile, text, auditory and visual. We describe the health BAN and a generic mobile health service platform and two context aware applications. The epilepsy application illustrates processing and interpretation of multi-source, multimedia BAN data. The chronic pain application illustrates multi-modal feedback and treatment, with patients able to view their own biosignals on their handheld device

Providing Preventive Oral Health Care to Infants and Young Children in Women, Infants, and Children (WIC), Early Head Start, and Primary Care Settings

This report focuses on seven oral health programs that provide preventive oral health care to young children (infants, toddlers, and children up to 5 years old) in Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), Early Head Start (EHS), and primary care settings. All of the programs strive to increase access to preventive oral health care by integrating dental services into primary care settings, WIC clinics, or EHS centers. These programs also rely on primary care providers (physicians, nurses, medical assistants, etc.) or new types of dental hygienists who can practice in community settings to deliver preventive oral health services. Two additional reports in this series describe the remaining programs that provide care in non-dental settings and programs designed to specifically address socioeconomic, cultural, and geographic barriers to preventive oral health care.The findings from the EAs of these programs are synthesized to highlight diverse and innovative strategies that are utilized to provide preventive oral health care in primary care settings, WIC clinics, or EHS centers. These strategies have potential for rigorous evaluation and could emerge as best practices. If proven effective, these innovative program elements could then be disseminated and replicated to increase access for populations in need of preventive oral health care

High acceptability of voluntary counselling and HIV-testing but unacceptable loss to follow up in a prevention of mother-to-child HIV transmission programme in rural Malawi: scaling-up requires a different way of acting.

SETTING: Thyolo District Hospital, rural Malawi. OBJECTIVES: In a prevention of mother-to-child HIV transmission (PMTCT) programme, to determine: the acceptability of offering 'opt-out' voluntary counselling and HIV-testing (VCT); the progressive loss to follow up of HIV-positive mothers during the antenatal period, at delivery and to the 6-month postnatal visit; and the proportion of missed deliveries in the district. DESIGN: Cohort study. METHODS: Review of routine antenatal, VCT and PMTCT registers. RESULTS: Of 3136 new antenatal mothers, 2996 [96%, 95% confidence interval (CI): 95-97] were pre-test counselled, 2965 (95%, CI: 94-96) underwent HIV-testing, all of whom were post-test counselled. Thirty-one (1%) mothers refused HIV-testing. A total of 646 (22%) individuals were HIV-positive, and were included in the PMTCT programme. Two hundred and eighty-eight (45%) mothers and 222 (34%) babies received nevirapine. The cumulative loss to follow up (n=646) was 358 (55%, CI: 51-59) by the 36-week antenatal visit, 440 (68%, CI: 64-71) by delivery, 450 (70%, CI: 66-73) by the first postnatal visit and 524 (81%, CI: 78-84) by the 6-month postnatal visit. This left just 122 (19%, CI: 16-22) of the initial cohort still in the programme. The great majority (87%) of deliveries occurred at peripheral sites where PMTCT was not available. CONCLUSIONS: In a rural district hospital setting, at least 9 out of every 10 mothers attending antenatal services accepted VCT, of whom approximately one-quarter were HIV-positive and included in the PMTCT programme. The progressive loss to follow up of more than three-quarters of this cohort by the 6-month postnatal visit demands a 'different way of acting' if PMTCT is to be scaled up in our setting

Implementing a Public Private Partnership Model for Managing Urban Health in Ahmedabad

Governments in many developing countries acknowledge they are facing difficulties in their attempt to meet the basic health needs of their populations. They rely on contracting out to private (for-profit and not-for-profit) organizations as a strategy to meet the needs of underserved populations. For the most part, the public sector chooses to contract out primary healthcare services to the private sector to expand access, increase the availability of medicines and medical supplies, and improve the quality of care. In both urban and rural settings, private for-profit and non-profit health service providers serve both the rich and the poor. Communities often recognize private sector healthcare providers to be more responsive to their healthcare needs and preferences in terms of services available, suitable timings and geographical access etc. Private sector has always played a significant role in the delivery of health services in developing countries. Public-private-partnership (PPP) is an approach under which services are delivered by the private sector, while the responsibility for providing the resources rests with the government. Establishing a PPP requires a legal framework acceptable to all the partners, clarity on the commitment of resources, roles and responsibilities of each partner, as well as accountability to provide a given set of services at a desired level of quality and affordable user charges. Formalizing such an arrangement between partners requires conceptualising a framework for Public Private Partnership (PPP) to manage the delivery of health services. In this paper, we describe the design, development and implementation of a PPP for managing urban health services in Ahmedabad city, Gujarat. Our model has succeeded in bringing together compatible public and private partners to plan and deliver quality healthcare services to meet the community needs of Vasna ward, in Ahmedabad. The new Vasna Urban Health centre was inaugurated on July 23, by the Chief Minister of Guajarat. This new centre now serves about 120 outpatients everyday as against an average of 10 outpatients daily earlier.

Delivering maternal and neonatal health interventions in conflict settings: A systematic review

Background: While much progress was made throughout the Millennium Development Goals era in reducing maternal and neonatal mortality, both remain unacceptably high, especially in areas affected by humanitarian crises. While valuable guidance on interventions to improve maternal and neonatal health in both non-crisis and crisis settings exists, guidance on how best to deliver these interventions in crisis settings, and especially in conflict settings, is still limited. This systematic review aimed to synthesise the available literature on the delivery on maternal and neonatal health interventions in conflict settings.Methods: We searched MEDLINE, Embase, CINAHL and PsycINFO databases using terms related to conflict, women and children, and maternal and neonatal health. We searched websites of 10 humanitarian organisations for relevant grey literature. Publications reporting on conflict-affected populations in low-income and middle-income countries and describing a maternal or neonatal health intervention delivered during or within 5 years after the end of a conflict were included. Information on population, intervention, and delivery characteristics were extracted and narratively synthesised. Quantitative data on intervention coverage and effectiveness were tabulated but no meta-analysis was undertaken.Results: 115 publications met our eligibility criteria. Intervention delivery was most frequently reported in the sub-Saharan Africa region, and most publications focused on displaced populations based in camps. Reported maternal interventions targeted antenatal, obstetric and postnatal care; neonatal interventions focused mostly on essential newborn care. Most interventions were delivered in hospitals and clinics, by doctors and nurses, and were mostly delivered through non-governmental organisations or the existing healthcare system. Delivery barriers included insecurity, lack of resources and lack of skilled health staff. Multi-stakeholder collaboration, the introduction of new technology or systems innovations, and staff training were delivery facilitators. Reporting of intervention coverage or effectiveness data was limited.Discussion: The relevant existing literature focuses mostly on maternal health especially around the antenatal period. There is still limited literature on postnatal care in conflict settings and even less on newborn care. In crisis settings, as much as in non-crisis settings, there is a need to focus on the first day of birth for both maternal and neonatal health. There is also a need to do more research on how best to involve community members in the delivery of maternal and neonatal health interventions.Prospero registration number: CRD42019125221