Household ownership and use of insecticide treated nets among target groups after implementation of a national voucher programme in the United Republic of Tanzania: plausibility study using three annual cross sectional household surveys.

OBJECTIVES: To evaluate the impact of the Tanzania National Voucher Scheme on the coverage and equitable distribution of insecticide treated nets, used to prevent malaria, to pregnant women and their infants. DESIGN: Plausibility study using three nationally representative cross sectional household and health facility surveys, timed to take place early, mid-way, and at the end of the roll out of the national programme. SETTING: The Tanzania National Voucher Scheme was implemented in antenatal services, and phased in on a district by district basis from October 2004 covering all of mainland Tanzania in May 2006. PARTICIPANTS: 6115, 6260, and 6198 households (in 2005, 2006, and 2007, respectively) in a representative sample of 21 districts (out of a total of 113). INTERVENTIONS: A voucher worth $2.45 ( pound1.47, euro1.74) to be used as part payment for the purchase of a net from a local shop was given to every pregnant woman attending antenatal services. MAIN OUTCOME MEASURES: Insecticide treated net coverage was measured as household ownership of at least one net and use of a net the night before the survey. Socioeconomic distribution of nets was examined using an asset based index. RESULTS: Steady increases in net coverage indicators were observed over the three year study period. Between 2005 and 2007, household ownership of at least one net (untreated or insecticide treated) increased from 44% (2686/6115) to 65% (4006/6198; P<0.001), and ownership of at least one insecticide treated net doubled from 18% (1062/5961) to 36% (2229/6198) in the same period (P<0.001). Among infants under 1 year of age, use of any net increased from 33% (388/1180) to 56% (707/1272; P<0.001) and use of an insecticide treated net increased from 16% (188/1180) to 34% (436/1272; P<0.001). After adjusting for potential confounders, household ownership was positively associated with time since programme launch, although this association did not reach statistical significance (P=0.09). Each extra year of programme operation was associated with a 9 percentage point increase in household insecticide treated net ownership (95% confidence interval -1.6 to 20). In 2005, only 7% (78/1115) of nets in households with a child under 1 year of age had been purchased with a voucher; this value increased to 50% (608/1211) in 2007 (P<0.001). In 2007, infants under 1 year in the least poor quintile were more than three times more likely to have used an insecticide treated net than infants in the poorest quintile (54% v 16%; P<0.001). CONCLUSIONS: The Tanzania National Voucher Scheme was associated with impressive increases in the coverage of insecticide treated nets over a two year period. Gaps in coverage remain, however, especially in the poorest groups. A voucher system that facilitates routine delivery of insecticide treated nets is a feasible option to "keep up" coverage

Preceptor Facilitated Debriefing Improves Athletic Training Student’s Clinical Performance and Work Efficacy

Debriefing is an essential part of healthcare training that utilizes a planned conversation to allow clinicians to analyze their actions, thought processes, and emotions with the goal of improving patient care and outcomes. Debriefing requires two-way communications between the athletic training student and facilitating preceptor. The process is more than providing feedback on clinical performance, but a communication process that fosters reflective insight into of behaviors and decisions. Debriefing after patient care encounters has been shown to increase critical thinking, confidence, clinical skill and clinical reasoning. With this enhancement in cognition and behavior, debriefing allows the student to strengthen their own capabilities and efficacy, better preparing themselves for real time clinical practice. Facilitating effective debriefing is challenging for seasoned educators, as well as practitioners untrained to facilitate effective debriefing

Assessment of a national voucher scheme to deliver insecticide-treated mosquito nets to pregnant women.

BACKGROUND: The benefits of a health-related intervention may be compromised by the challenges of delivering the intervention on a large scale. We analyzed the process involved in the Tanzania National Voucher Scheme, a system for delivering insecticide-treated mosquito nets to pregnant women. We aimed to identify potential ways to equitably improve overall coverage of the intervention. METHODS: We defined five steps in the process. We collected data from a multistage cluster survey of nationally representative households conducted in 2007 across 21 districts in Tanzania. Using these data, we multiplied the rate of success of each step cumulatively to estimate the overall success of the system. RESULTS: The rate of coverage for use of insecticide-treated nets among pregnant women was 23% (95% confidence interval [CI] 19%-27%). We observed large differences in coverage by socio-economic status, from 7% (95% CI 4%-13%) among participants in the poorest households to 48% (95% CI 38%-59%) among those in the richest households. The rate of success of each step in the process was high (60%-98%). However, the cumulative rate of success for the process as a whole was low (30%). The largest and most inequitable reduction in coverage occurred in the step involving treatment of nets with insecticide. INTERPRETATION: The cumulative effect of modest attrition at several steps in the process substantially diminished the overall rate of coverage for all women, but most markedly among the poorest participants. Analysis of the process suggests that delivery of nets treated with long-lasting insecticide rather than untreated nets packaged with an insecticide-treatment kit could result in an improvement in coverage of 22 percentage points, from 30% to 52%

Development of a Coupled Ocean–Atmosphere–Wave–Sediment Transport (COAWST) Modeling System

This paper is not subject to U.S. copyright. The definitive version was published in Ocean Modelling 35 (2010): 230-244, doi:10.1016/j.ocemod.2010.07.010.Understanding the processes responsible for coastal change is important for managing our coastal resources, both natural and economic. The current scientific understanding of coastal sediment transport and geology suggests that examining coastal processes at regional scales can lead to significant insight into how the coastal zone evolves. To better identify the significant processes affecting our coastlines and how those processes create coastal change we developed a Coupled Ocean–Atmosphere–Wave–Sediment Transport (COAWST) Modeling System, which is comprised of the Model Coupling Toolkit to exchange data fields between the ocean model ROMS, the atmosphere model WRF, the wave model SWAN, and the sediment capabilities of the Community Sediment Transport Model. This formulation builds upon previous developments by coupling the atmospheric model to the ocean and wave models, providing one-way grid refinement in the ocean model, one-way grid refinement in the wave model, and coupling on refined levels. Herein we describe the modeling components and the data fields exchanged. The modeling system is used to identify model sensitivity by exchanging prognostic variable fields between different model components during an application to simulate Hurricane Isabel during September 2003. Results identify that hurricane intensity is extremely sensitive to sea surface temperature. Intensity is reduced when coupled to the ocean model although the coupling provides a more realistic simulation of the sea surface temperature. Coupling of the ocean to the atmosphere also results in decreased boundary layer stress and coupling of the waves to the atmosphere results in increased bottom stress. Wave results are sensitive to both ocean and atmospheric coupling due to wave–current interactions with the ocean and wave growth from the atmosphere wind stress. Sediment resuspension at regional scale during the hurricane is controlled by shelf width and wave propagation during hurricane approach

Techno–ecological synergies of solar energy for global sustainability

The strategic engineering of solar energy technologies—from individual rooftop modules to large solar energy power plants—can confer significant synergistic outcomes across industrial and ecological boundaries. Here, we propose techno–ecological synergy (TES), a framework for engineering mutually beneficial relationships between technological and ecological systems, as an approach to augment the sustainability of solar energy across a diverse suite of recipient environments, including land, food, water, and built-up systems. We provide a conceptual model and framework to describe 16 TESs of solar energy and characterize 20 potential techno–ecological synergistic outcomes of their use. For each solar energy TES, we also introduce metrics and illustrative assessments to demonstrate techno–ecological potential across multiple dimensions. The numerous applications of TES to solar energy technologies are unique among energy systems and represent a powerful frontier in sustainable engineering to minimize unintended consequences on nature associated with a rapid energy transition

Chromatin-modifying enzymes as modulators of reprogramming

Generation of induced pluripotent stem cells (iPSCs) by somatic cell reprogramming involves global epigenetic remodelling. Whereas several proteins are known to regulate chromatin marks associated with the distinct epigenetic states of cells before and after reprogramming, the role of specific chromatin-modifying enzymes in reprogramming remains to be determined. To address how chromatin-modifying proteins influence reprogramming, we used short hairpin RNAs (shRNAs) to target genes in DNA and histone methylation pathways, and identified positive and negative modulators of iPSC generation. Whereas inhibition of the core components of the polycomb repressive complex 1 and 2, including the histone 3 lysine 27 methyltransferase EZH2, reduced reprogramming efficiency, suppression of SUV39H1, YY1 and DOT1L enhanced reprogramming. Specifically, inhibition of the H3K79 histone methyltransferase DOT1L by shRNA or a small molecule accelerated reprogramming, significantly increased the yield of iPSC colonies, and substituted for KLF4 and c-Myc (also known as MYC). Inhibition of DOT1L early in the reprogramming process is associated with a marked increase in two alternative factors, NANOG and LIN28, which play essential functional roles in the enhancement of reprogramming. Genome-wide analysis of H3K79me2 distribution revealed that fibroblast-specific genes associated with the epithelial to mesenchymal transition lose H3K79me2 in the initial phases of reprogramming. DOT1L inhibition facilitates the loss of this mark from genes that are fated to be repressed in the pluripotent state. These findings implicate specific chromatin-modifying enzymes as barriers to or facilitators of reprogramming, and demonstrate how modulation of chromatin-modifying enzymes can be exploited to more efficiently generate iPSCs with fewer exogenous transcription factors. © 2012 Macmillan Publishers Limited. All rights reserved

Vouchers for scaling up insecticide-treated nets in Tanzania: Methods for monitoring and evaluation of a national health system intervention

BACKGROUND: The Tanzania National Voucher Scheme (TNVS) uses the public health system and the commercial sector to deliver subsidised insecticide-treated nets (ITNs) to pregnant women. The system began operation in October 2004 and by May 2006 was operating in all districts in the country. Evaluating complex public health interventions which operate at national level requires a multidisciplinary approach, novel methods, and collaboration with implementers to support the timely translation of findings into programme changes. This paper describes this novel approach to delivering ITNs and the design of the monitoring and evaluation (M&E). METHODS: A comprehensive and multidisciplinary M&E design was developed collaboratively between researchers and the National Malaria Control Programme. Five main domains of investigation were identified: (1) ITN coverage among target groups, (2) provision and use of reproductive and child health services, (3) "leakage" of vouchers, (4) the commercial ITN market, and (5) cost and cost-effectiveness of the scheme. RESULTS: The evaluation plan combined quantitative (household and facility surveys, voucher tracking, retail census and cost analysis) and qualitative (focus groups and in-depth interviews) methods. This plan was defined in collaboration with implementing partners but undertaken independently. Findings were reported regularly to the national malaria control programme and partners, and used to modify the implementation strategy over time. CONCLUSION: The M&E of the TNVS is a potential model for generating information to guide national and international programmers about options for delivering priority interventions. It is independent, comprehensive, provides timely results, includes information on intermediate processes to allow implementation to be modified, measures leakage as well as coverage, and measures progress over time

The Lantern, 2016-2017

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