Tuberculosis laboratory information systems for resource-poor settings

Thesis (Ph. D.)--Harvard-MIT Division of Health Sciences and Technology, February 2009.Includes bibliographical references (p. 132-143).Multi-drug resistant tuberculosis (MDR-TB) patients in resource-poor settings experience large delays in starting appropriate drug regimens and are often not monitored appropriately due to an overburdened health care system, communication delays, and missing or error-prone data. Medical information systems can be used to alleviate these problems by increasing the timeliness and quality of laboratory information available. The research reported in this thesis developed, implemented, and evaluated two such systems in the urban, resource-poor setting of Lima, Peru in institutions with and without internet. The first part addresses the electronic collection of tuberculosis (TB) laboratory information from multiple institutions without internet. A handheld computer-based system was developed and implemented. A cluster randomized controlled trial and before-and-after comparison showed that this system had a significant effect in reducing processing times from 23 to 8 days, the proportion of cultures with delays >90 days from 9.2% to 0.1%, the number of errors by 57.1%, and the work-hours necessary to process results by 60%. A cost and timeline framework was developed to allow other organizations in resource-poor settings to implement this technology. The second part addresses a web-based system, e-Chasqui, developed to provide electronic communication and reporting of TB laboratory information to health care personnel within institutions with internet. A cluster randomized controlled trial showed that access to e-Chasqui resulted in significantly less time to receipt of test results, a 56% reduction in tests taking over 60 days to arrive and a 98% reduction of results that never arrived, as well as a significantly faster time to culture conversion among patients in intervention versus control centers.(cont.) These two parts describe verified medical informatics tools and an implementation methodology for settings both with and without internet connectivity.by Joaquin Andres Blaya.Ph.D

Addressing climate change with behavioral science: a global intervention tournament in 63 countries

Effectively reducing climate change requires marked, global behavior change. However, it is unclear which strategies are most likely to motivate people to change their climate beliefs and behaviors. Here, we tested 11 expert-crowdsourced interventions on four climate mitigation outcomes: beliefs, policy support, information sharing intention, and an effortful tree-planting behavioral task. Across 59,440 participants from 63 countries, the interventions’ effectiveness was small, largely limited to nonclimate skeptics, and differed across outcomes: Beliefs were strengthened mostly by decreasing psychological distance (by 2.3%), policy support by writing a letter to a future-generation member (2.6%), information sharing by negative emotion induction (12.1%), and no intervention increased the more effortful behavior—several interventions even reduced tree planting. Last, the effects of each intervention differed depending on people’s initial climate beliefs. These findings suggest that the impact of behavioral climate interventions varies across audiences and target behaviors

Addressing climate change with behavioral science:A global intervention tournament in 63 countries

Effectively reducing climate change requires marked, global behavior change. However, it is unclear which strategies are most likely to motivate people to change their climate beliefs and behaviors. Here, we tested 11 expert-crowdsourced interventions on four climate mitigation outcomes: beliefs, policy support, information sharing intention, and an effortful tree-planting behavioral task. Across 59,440 participants from 63 countries, the interventions' effectiveness was small, largely limited to nonclimate skeptics, and differed across outcomes: Beliefs were strengthened mostly by decreasing psychological distance (by 2.3%), policy support by writing a letter to a future-generation member (2.6%), information sharing by negative emotion induction (12.1%), and no intervention increased the more effortful behavior-several interventions even reduced tree planting. Last, the effects of each intervention differed depending on people's initial climate beliefs. These findings suggest that the impact of behavioral climate interventions varies across audiences and target behaviors.</p

Addressing climate change with behavioral science:A global intervention tournament in 63 countries

Effectively reducing climate change requires marked, global behavior change. However, it is unclear which strategies are most likely to motivate people to change their climate beliefs and behaviors. Here, we tested 11 expert-crowdsourced interventions on four climate mitigation outcomes: beliefs, policy support, information sharing intention, and an effortful tree-planting behavioral task. Across 59,440 participants from 63 countries, the interventions' effectiveness was small, largely limited to nonclimate skeptics, and differed across outcomes: Beliefs were strengthened mostly by decreasing psychological distance (by 2.3%), policy support by writing a letter to a future-generation member (2.6%), information sharing by negative emotion induction (12.1%), and no intervention increased the more effortful behavior-several interventions even reduced tree planting. Last, the effects of each intervention differed depending on people's initial climate beliefs. These findings suggest that the impact of behavioral climate interventions varies across audiences and target behaviors.</p

Force-controllable AFO to assist drop foot gait

Thesis (S.M.)--Massachusetts Institute of Technology, Dept. of Mechanical Engineering, February 2003.Includes bibliographical references (leaves 81-85).Drop foot, a loss of use of the muscles that lift the foot, can be caused by stroke, cerebral palsy (CP), multiple sclerosis (MS), or neurological trauma. The two major complications of drop foot are slapping of the foot after heel strike (foot slap) and dragging of the toe during swing (toe drag). The current assistive device is the Ankle Foot Orthosis (AFO), which though offering some biomechanical benefits, is nonadaptive and fails to eliminate significant gait complications. An Active Ankle Foot Orthosis (AAFO) is presented where the impedance of the orthotic joint is modulated throughout the walking cycle to treat drop foot gait. To prevent foot slap, a biomimetic torsional spring control is applied where orthotic joint stiffness is actively adjusted to minimize forefoot collisions with the ground. Throughout late stance, joint impedance is minimized so as not to impede powered plantar flexion movements, and during the swing phase, a torsional spring-damper (PD) control lifts the foot to provide toe clearance. To assess the clinical effects of variable-impedance control, kinetic and kinematic gait data were collected on two drop foot participants wearing the AAFO. For each participant, zero, constant and variable impedance control strategies were evaluated, and the results were compared to the mechanics of three age, weight and height matched normals. It was found that actively adjusting joint impedance significantly reduces the occurrence of slap foot, allows greater powered plantar flexion, and provides for greater biological realism in swing phase ankle dynamics. These results indicate that a variable-impedance orthosis may have certain clinical benefits for the treatment of drop foot gait compared to conventional AFO having zero or constant stiffness joint behaviors.by Joaquin A. Blaya.S.M

A web-based laboratory information system to improve quality of care of tuberculosis patients in Peru: functional requirements, implementation and usage statistics

Background: Multi-drug resistant tuberculosis patients in resource-poor settings experience large delays in starting appropriate treatment and may not be monitored appropriately due to an overburdened laboratory system, delays in communication of results, and missing or error-prone laboratory data. The objective of this paper is to describe an electronic laboratory information system implemented to alleviate these problems and its expanding use by the Peruvian public sector, as well as examine the broader issues of implementing such systems in resource-poor settings. Methods: A web-based laboratory information system "e-Chasqui" has been designed and implemented in Peru to improve the timeliness and quality of laboratory data. It was deployed in the national TB laboratory, two regional laboratories and twelve pilot health centres. Using needs assessment and workflow analysis tools, e-Chasqui was designed to provide for improved patient care, increased quality control, and more efficient laboratory monitoring and reporting. Results: Since its full implementation in March 2006, 29,944 smear microscopy, 31,797 culture and 7,675 drug susceptibility test results have been entered. Over 99% of these results have been viewed online by the health centres. High user satisfaction and heavy use have led to the expansion of e-Chasqui to additional institutions. In total, e-Chasqui will serve a network of institutions providing medical care for over 3.1 million people. The cost to maintain this system is approximately US$0.53 per sample or 1% of the National Peruvian TB program's 2006 budget. Conclusion: Electronic laboratory information systems have a large potential to improve patient care and public health monitoring in resource-poor settings. Some of the challenges faced in these settings, such as lack of trained personnel, limited transportation, and large coverage areas, are obstacles that a well-designed system can overcome. e-Chasqui has the potential to provide a national TB laboratory network in Peru. Furthermore, the core functionality of e-Chasqui as been implemented in the open source medical record system OpenMRS http://www.openmrs.org for other countries to use.Harvard University. Global Infectious Diseases ProgramDavid Rockefeller Center for Latin American StudiesMassachusetts Institute of Technology. Public Service CenterMassachusetts Institute of Technology. Office of the Dean for Graduate Educatio

Information Systems for Patient Follow-Up and Chronic Management of HIV and Tuberculosis: A Life-Saving Technology in Resource-Poor Areas

Reviewer: Mark, LindaReviewer: Pourmalek, Farshad[This item is a preserved copy and is not necessarily the most recent version. To view the current item, visit http://www.jmir.org/2007/4/e29/ ] Background: The scale-up of treatment for HIV and multidrug-resistant tuberculosis (MDR-TB) in developing countries requires a long-term relationship with the patient, accurate and accessible records of each patient’s history, and methods to track his/her progress. Recent studies have shown up to 24% loss to follow-up of HIV patients in Africa during treatment and many patients not being started on treatment at all. Some programs for prevention of maternal–child transmission have more than 80% loss to follow-up of babies born to HIV-positive mothers. These patients are at great risk of dying or developing drug resistance if their antiretroviral therapy is interrupted. Similar problems have been found in the scale-up of MDR-TB treatment. Objectives: The aim of the study was to assess the role of medical information systems in tracking patients with HIV or MDR-TB, ensuring they are promptly started on high quality care, and reducing loss to follow-up. Methods: A literature search was conducted starting from a previous review and using Medline and Google Scholar. Due to the nature of this work and the relative lack of published articles to date, the authors also relied on personal knowledge and experience of systems in use and their own assessments of systems. Results: Functionality for tracking patients and detecting those lost to follow-up is described in six HIV and MDR-TB treatment projects in Africa and Latin America. Preliminary data show benefits in tracking patients who have not been prescribed appropriate drugs, those who fail to return for follow-up, and those who do not have medications picked up for them by health care workers. There were also benefits seen in providing access to key laboratory data and in using this data to improve the timeliness and quality of care. Follow-up was typically achieved by a combination of reports from information systems along with teams of community health care workers. New technologies such as low-cost satellite Internet access, personal digital assistants, and cell phones are helping to expand the reach of these systems. Conclusions: Effective information systems in developing countries are a recent innovation but will need to play an increasing role in supporting and monitoring HIV and MDR-TB projects as they scale up from thousands to hundreds of thousands of patients. A particular focus should be placed on tracking patients from initial diagnosis to initiation of effective treatment and then monitoring them for treatment breaks or loss to follow-up. More quantitative evaluations need to be performed on the impact of electronic information systems on tracking patients