Studying complex interventions : reflections from the FEMHealth project on evaluating fee exemption policies in West Africa and Morocco

Peer reviewedPublisher PD

Performance-based financing as a health system reform : mapping the key dimensions for monitoring and evaluation

Peer reviewedPublisher PD

Digital Atlas of Anatomical Subdivisions and Boundaries of the Rat Hippocampal Region

The rat hippocampal region is frequently studied in relation to learning and memory processes and brain diseases. The region is complex, consisting of multiple subdivisions that are challenging to delineate anatomically. Published atlases of the rat brain typically lack the underlying histological criteria necessary to identify boundaries, and textbooks descriptions of the region are often inadequately illustrated and thus difficult to relate to experimental data. An overview of both anatomical features and criteria used to delineate boundaries is required to assign location to experimental material from the hippocampal region. To address this issue, we have developed a web-based atlas application in which images of histological sections are integrated with new and up-to-date criteria for subdividing the rat hippocampus formation, fasciola, and associated parahippocampal regions. The atlas application consists of an interactive image viewer with high-resolution images of an extensive series of sections stained for NeuN, calbindin, and parvalbumin, and an index of structures with detailed descriptions of the criteria used to define the boundaries. Images can be inspected with a graphical overlay of selected subregions. Bi-directional links between images and the index of structures are provided. In summary, we provide a novel content-rich digital atlas resource facilitating identification of morphological features relevant for delineating the anatomical subdivisions of the rat hippocampal region. The atlas application is available at http://www.rbwb.org

Working practices and incomes of health workers : evidence from an evaluation of a delivery fee exemption scheme in Ghana

Background: This article describes a survey of health workers and traditional birth attendants (TBAs) which was carried out in 2005 in two regions of Ghana. The objective of the survey was to ascertain the impact of the introduction of a delivery fee exemption scheme on both health workers and those providers who were excluded from the scheme (TBAs). This formed part of an overall evaluation of the delivery fee exemption scheme. The results shed light not only on the scheme itself but also on the general productivity of a range of health workers in Ghana. Methods: A structured questionnaire was developed, covering individual and household characteristics, working hours and practices, sources of income, and views of the exemptions scheme and general motivation. After field testing, this was administered to 374 respondents in 12 districts of Central and Volta regions. The respondents included doctors, medical assistants (MAs), public and private midwives, nurses, community health nurses (CHNs), and traditional birth attendants, both trained and untrained. Results: Health workers were well informed about the delivery fee exemptions scheme and their responses on its impact suggest a realistic view that it was a good scheme, but one that faces serious challenges regarding financial sustainability. Concerning its impact on their morale and working conditions, the responses were broadly neutral. Most public sector workers have seen an increased workload, but counterbalanced by increased pay. TBAs have suffered, in terms of client numbers and income, while the picture for private midwives is mixed. The survey also sheds light on pay and productivity. The respondents report long working hours, with a mean of 54 hours per week for community nurses and up to 129 hours per week for MAs. Weekly reported client loads in the public sector range from a mean of 86 for nurses to 269 for doctors. Over the past two years, reported working hours have been increasing, but so have pay and allowances (for doctors, allowances now make up 66% of their total pay). The lowest paid public health worker now earns almost ten times the average gross national income (GNI) per capita, while the doctors earn 38.5 times GNI per capita. This compares well with average government pay of four times GNI per capita. Comparing pay with outputs, the relatively high number of clients reported by doctors reduces their pay differential, so that the cost per client – $1.09 – is similar to a nurse's (and lower than a private midwife's). Conclusion: These findings show that a scheme which increases demand for public health services while also sustaining health worker income and morale, is workable, if well managed, even within the relatively constrained human resources environment of countries like Ghana. This may be linked to the fact that internal comparisons reveal Ghana's health workers to be well paid from public sector sources.This work was undertaken as part of an international research programme – IMMPACT (Initiative for Maternal Mortality Programme Assessment) – funded by the Bill & Melinda Gates Foundation, the Department for International Development, the European Commission and USAID

What Does the Anatomical Organization of the Entorhinal Cortex Tell Us?

The entorhinal cortex is commonly perceived as a major input and output structure of the hippocampal formation, entertaining the role of the nodal point of cortico-hippocampal circuits. Superficial layers receive convergent cortical information, which is relayed to structures in the hippocampus, and hippocampal output reaches deep layers of entorhinal cortex, that project back to the cortex. The finding of the grid cells in all layers and reports on interactions between deep and superficial layers indicate that this rather simplistic perception may be at fault. Therefore, an integrative approach on the entorhinal cortex, that takes into account recent additions to our knowledge database on entorhinal connectivity, is timely. We argue that layers in entorhinal cortex show different functional characteristics most likely not on the basis of strikingly different inputs or outputs, but much more likely on the basis of differences in intrinsic organization, combined with very specific sets of inputs. Here, we aim to summarize recent anatomical data supporting the notion that the traditional description of the entorhinal cortex as a layered input-output structure for the hippocampal formation does not give the deserved credit to what this structure might be contributing to the overall functions of cortico-hippocampal networks

Differences in intestinal size, structure, and function contributing to feed efficiency in broiler chickens reared at geographically distant locations

The contribution of the intestinal tract to differences in residual feed intake (RFI) has been inconclusively studied in chickens so far. It is also not clear if RFI-related differences in intestinal function are similar in chickens raised in different environments. The objective was to investigate differences in nutrient retention, visceral organ size, intestinal morphology, jejunal permeability and expression of genes related to barrier function, and innate immune response in chickens of diverging RFI raised at 2 locations (L1: Austria; L2: UK). The experimental protocol was similar, and the same dietary formulation was fed at the 2 locations. Individual BW and feed intake (FI) of chickens (Cobb 500FF) were recorded from d 7 of life. At 5 wk of life, chickens (L1, n = 157; L2 = 192) were ranked according to their RFI, and low, medium, and high RFI chickens were selected (n = 9/RFI group, sex, and location). RFI values were similar between locations within the same RFI group and increased by 446 and 464 g from low to high RFI in females and males, respectively. Location, but not RFI rank, affected growth, nutrient retention, size of the intestine, and jejunal disaccharidase activity. Chickens from L2 had lower total body weight gain and mucosal enzyme activity but higher nutrient retention and longer intestines than chickens at L1. Parameters determined only at L1 showed increased crypt depth in the duodenum and jejunum and enhanced paracellular permeability in low vs. high RFI females. Jejunal expression of IL1B was lower in low vs. high RFI females at L2, whereas that of TLR4 at L1 and MCT1 at both locations was higher in low vs. high RFI males. Correlation analysis between intestinal parameters and feed efficiency metrics indicated that feed conversion ratio was more correlated to intestinal size and function than was RFI. In conclusion, the rearing environment greatly affected intestinal size and function, thereby contributing to the variation in chicken RFI observed across locations

Classification of Marek's disease viruses according to pathotype: Philosophy and methodology

El concepto de patotipo en la enfermedad de Marek (MD) data probablemente de finales de los 1950s cuando se reconoció una forma más virulenta de enfermedad Benton y Cover, 1957). Las distinciones entre las diferentes cepas de virus de MD (MDV) fueron aún mayores al describirse el patotipo vv a principios de los ochenta y el vv+ en los noventa. La designación de patotipo refleja propiedades biológicas importantes que se correlacionan con la capacidad de romper la inmunidad maternal en el campo. A pesar de ello, los métodos de clasificación de los diferentes patotipos en varios laboratorios no han sido uniformes, lo cual ha impedido una comparación crítica de los resultados. El método utilizado en el Avian Disease and Oncology Laboratory (ADOL) se basa en la inducción de lesiones linfoproliferativas en pollos vacunados. Este método ha sido utilizado para clasificar más de 45 aislados y es la base para la clasificación actual de los patotipos de cepas de MDV. Las limitaciones de este método son varias: necesidad de un tipo específico de pollos (15x7 ab+), uso de un gran número de animales y de un método estadístico para comparar las respuestas lesionales con las de las cepas control JM/102W y Md5. Debido a estas limitaciones no ha sido y no es probablemente usado en otros laboratorios. La comparación en el patotipado puede ser mejorada mediante la comparación de aislados de campo con cepas prototipo como las JM/102W, Md5 y 648A (American Type Culture Collection) o sus equivalentes. Los datos pueden ser generados mediante diferentes procedimientos in vivo que miden la inducción de tumores, enfermedad neurològica (por lesiones neoplásicas o no neoplásicas), o únicamente por criterios no neoplásicos (como el peso de los órganos linfoides o la replicación vírica). Los métodos basados en criterios neoplásicos, especialmente cuando son generados en pollos inmunizados de MD, probablemente se correlacionarán mejor con el método del ADOL y serán más relevantes en cuanto a la evolución de los virus de MD en el campo. En base a los datos de diferentes experimentos, se propone una modificación del método ADOL que utiliza menos animales y puede ser llevado a cabo en pollos SPF comerciales. El método modificado se basa en una comparación con el que mejor clasifica las cepas prototipo, y se espera que de resultados en general comparables con el método original. Otros criterios alternativos (ver abajo) también se evalúan como métodos primarios de patotipificación o como adjuntos a otros métodos de patotipificación. Se presentan las ventajas y desventajas de estos métodos alternativos.The concept of pathotype in Marek's disease (MD) probably dates from the recognition of a more virulent form of the disease in the late 1950s (Benton & Cover, 1957). Distinctions between MD virus strains were further expanded with the description of the vv pathotype in the early 1980s and of the vv + pathotype in the 1990s. Pathotype designations reflect important biological properties that correlate with the break-through of vaccinal immunity in the field. However, pathotyping methods applied by various laboratories have not been uniform, preventing critical comparison of results. Better uniformity of pathotyping procedures is desirable. The Avian Disease and Oncology Laboratory (ADOL) method is based on induction of lymphoproliferative lesions in vaccinated chickens. This method has been used to pathotype more than 45 isolates and is the basis for the current pathotype classification of MD virus strains. Its limitations include requirements for a specific type of chickens (15 x 7 ab+), large numbers of animals, and a statistical method to compare lesion responses to those of JM/102W and Md5 control strains. Because of these limitations, it has not been and is not likely to be used in other laboratories. Comparability in pathotyping can be improved by the comparison of field isolates with standard prototype strains such as JM/102W, Md5 and 648A (American Type Culture Collection) or their equivalents. Data may be generated by different in vivo procedures that measure tumour induction, neurological disease (both neoplastic and non-neoplastic lesions), or solely non-neoplastic criteria (such as lymphoid organ weights or virus replication). Methods based on neoplastic criteria, especially when generated in MD-immunized chickens, will probably correlate most closely with that of the ADOL method and be most relevant to evolution of MD virus in the field. Based on data from several trials, a modification of the ADOL method that utilizes fewer chickens and can be conducted with commercial specific pathogen free strains is proposed. The modified method is based on "best fit" comparisons with prototype strains, and is expected to provide results generally comparable with the original method. A variety of other alternative criteria (see earlier) are also evaluated both for primary pathotyping and as adjuncts to other pathotyping methods. Advantages and disadvantages of alternative methods are presented.Facultad de Ciencias Veterinaria

Rural-urban health seeking behaviours for non-communicable diseases in Sierra Leone

Ayesha Idriss - ORCID 0000-0001-9926-2542 https://orcid.org/0000-0001-9926-2542Karin Diaconu - ORCID 0000-0002-5810-9725 https://orcid.org/0000-0002-5810-9725Sophie Witter - ORCID 0000-0002-7656-6188 https://orcid.org/0000-0002-7656-6188Introduction Non-communicable diseases (NCDs) are the leading cause of mortality globally. In Africa, they are expected to increase by 25% by 2030. However, very little is known about community perceptions of risk factors and factors influencing health-seeking behaviour, especially in fragile settings. Understanding these is critical to effectively address this epidemic, especially in low-resource settings.Methods We use participatory group model building techniques to probe knowledge and perceptions of NCD conditions and their causes, health-seeking patterns for NCDs and factors affecting these health-seeking patterns. Our participants were 116 local leaders and community members in three sites in Western Area (urban) and Bombali District (rural), Sierra Leone. Data were analysed using a prior framework for NCD care seeking developed in Ghana.Results Our findings suggest adequate basic knowledge of causes and symptoms of the common NCDs, in rural and urban areas, although there is a tendency to highlight and react to severe symptoms. Urban and rural communities have access to a complex network of formal and informal, traditional and biomedical, spiritual and secular health providers. We highlight multiple narratives of causal factors which community members can hold, and how these and social networks influence their care seeking. Care seeking is influenced by a number of factors, including supply-side factors (proximity and cost), previous experiences of care, disease-specific factors, such as acute presentation, and personal and community beliefs about the appropriateness of different strategies.Conclusion This article adds to the limited literature on community understanding of NCDs and its associated health-seeking behaviour in fragile settings. It is important to further elucidate these factors, which power hybrid journeys including non-care seeking, failure to prevent and self-manage effectively, and considerable expenditure for households, in order to improve prevention and management of NCDs in fragile settings such as Sierra Leone.This study received funding support from the National Institute for Health Research.https://doi.org/10.1136/bmjgh-2019-0020245pubpub

Opportunities and challenges for delivering non-communicable disease management and services in fragile and post-conflict settings: Perceptions of policy-makers and health providers in Sierra Leone

Sophie Witter - ORCID 0000-0002-7656-6188 https://orcid.org/0000-0002-7656-6188Karin Diaconu - ORCID 0000-0002-5810-9725 https://orcid.org/0000-0002-5810-9725Background: The growing burden of non-communicable diseases in low- and middle-income countries presents substantive challenges for health systems. This is also the case in fragile, post-conflict and post-Ebola Sierra Leone, where NCDs represent an increasingly significant disease burden (around 30% of adult men and women have raised blood pressure). To date, documentation of health system challenges and opportunities for NCD prevention and control is limited in such settings. This paper aims to identify opportunities and challenges in provision of NCD prevention and care and highlight lessons for Sierra Leone and other fragile states in the battle against the growing NCD epidemic.Methods: This paper focuses on the case of Sierra Leone and uses a combination of participatory group model building at national and district level, in rural and urban districts, interviews with 28 key informants and review of secondary data and documents. Data is analysed using the WHO’s health system assessment guide for NCDs.Results: We highlight multiple challenges typical to those encountered in other fragile settings to the delivery of preventive and curative NCD services. There is limited government and donor commitment to financing and implementation of the national NCD policy and strategy, limited and poorly distributed health workforce and pharmaceuticals, high financial barriers for users, and lack of access to quality-assured medicines with consequent high recourse to private and informal care seeking. We identify how to strengthen the system within existing (low) resources, including through improved clinical guides and tools, more effective engagement with communities, and regulatory and fiscal measures.Conclusion: Our study suggests that NCD prevention and control is of low but increasing priority in Sierra Leone; challenges to addressing this burden relate to huge numbers with NCDs (especially hypertension) requiring care, overall resource constraints and wider systemic issues, including poorly supported primary care services and access barriers. In addition to securing and strengthening political will and commitment and directing more resources and attention towards this area, there is a need for in-depth exploratory and implementation research to shape and test NCD interventions in fragile and post-conflict settings.This study/project is funded by the National Institute for Health Research (NIHR) [NIHR Global Health Research programme (project reference 16/136/ 100)/NIHR Research Unit on Health in Situations of Fragility]. The views expressed are those of the author (s) and not necessarily those of the NIHR or the Department of Health and Social Care. We would like to thank all who contributed insights through their participation in our research.https://doi.org/10.1186/s13031-019-0248-314pubpub

Eddy–Mean Flow Interaction in Zonal Oceanic Jet Flow along Zonal Ridge Topography

Motivated by satellite altimeter observations of enhanced sea level variability near steep topographic slopes in the Southern Ocean, effects of topography on the spatial distribution of mesoscale eddies and on eddy–mean flow interaction are investigated using a two-layer, wind-forced, quasigeostrophic channel model. The principal topography, a zonal ridge with a zonal modulation of ridge height and width, is an idealized version of a segment of the Southeast Indian Ridge along the path of the Antarctic Circumpolar Current. Geosat altimeter observations in this region suggest that spatial variations of eddy energy are related to alongstream modulations of ridge morphology. The time-mean flow and distribution of time-dependent eddies in the model are sensitive to relatively subtle alongstream variations of topography. Topographic steering leads to alongstream variations of time-mean baroclinic and barotropic shear and to alongstream variations in the meridional position of the jet relative to the crest of the zonal ridge. Linear stability analysis demonstrates that zonal variations of flow stability are strongly coupled to the topography. Unstable mode growth rates are largest where topographic steering forces the jet into regions of reduced ambient potential vorticity gradient. Growth rates are lower where topography steers the jet into regions of higher ambient potential vorticity gradient. As a result, the largest eddy energies occur downstream of zonal modulations of ridge height or width. Unlike flows over flat-bottom topography, the zonal distribution of unstable mode growth rate is negatively correlated with velocity shear. Analysis of area-averaged mean-to-eddy energy conversions shows that zonal modulations of topography modify the regime of flow instability. Baroclinic instability and recycling of eddy energy in the upper part of the water column occur in cases with zonally uniform topography. Mixed baroclinic–barotropic instability and strong downward transfers of eddy energy occur in cases with zonal modulations of topography. Local vorticity analyses demonstrate that alongstream variations of topography produce strong zonal modulations of flow dynamics. Zonal variations of topography shift the region of eddy-influenced dynamics within the model domain and modify the relative contributions of the mean and eddy field to the time-mean vorticity balance. When interpreted in the context of Southern Ocean dynamics, these results suggest that eddy-active regions near steep topographic slopes may contribute disproportionately to the dynamics of the Antarctic Circumpolar Current