Can Action Research Strengthen District Health Management and Improve Health Workforce Performance? A Research Protocol.

The single biggest barrier for countries in sub-Saharan Africa (SSA) to scale up the necessary health services for addressing the three health-related Millennium Development Goals and achieving Universal Health Coverage is the lack of an adequate and well-performing health workforce. This deficit needs to be addressed both by training more new health personnel and by improving the performance of the existing and future health workforce. However, efforts have mostly been focused on training new staff and less on improving the performance of the existing health workforce. The purpose of this paper is to disseminate the protocol for the PERFORM project and reflect on the key challenges encountered during the development of this methodology and how they are being overcome. The overall aim of the PERFORM project is to identify ways of strengthening district management in order to address health workforce inadequacies by improving health workforce performance in SSA. The study will take place in three districts each in Ghana, Tanzania and Uganda using an action research approach. With the support of the country research teams, the district health management teams (DHMTs) will lead on planning, implementation, observation, reflection and redefinition of the activities in the study. Taking into account the national and local human resource (HR) and health systems (HS) policies and practices already in place, 'bundles' of HR/HS strategies that are feasible within the context and affordable within the districts' budget will be developed by the DHMTs to strengthen priority areas of health workforce performance. A comparative analysis of the findings from the three districts in each country will add new knowledge on the effects of these HR/HS bundles on DHMT management and workforce performance and the impact of an action research approach on improving the effectiveness of the DHMTs in implementing these interventions. Different challenges were faced during the development of the methodology. These include the changing context in the study districts, competing with other projects and duties for the time of district managers, complexity of the study design, maintaining the anonymity and confidentiality of study participants as well as how to record the processes during the study. We also discuss how these challenges are being addressed. The dissemination of this research protocol is intended to generate interest in the PERFORM project and also stimulate discussion on the use of action research in complex studies such as this on strengthening district health management to improve health workforce performance

Effects of a Novel Ground-Based Movement Training Program on Functional Movement, Flexibility, Strength and Endurance

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Towards diagnostic conversational profiles of patients presenting with dementia or functional memory disorders to memory clinics

Objective: This study explores whether the profile of patients' interactional behaviour in memory clinic conversations with a doctor can contribute to the clinical differentiation between functional memory disorders (FMD) and memory problems related to neurodegenerative diseases. Methods: Conversation Analysis of video recordings of neurologists' interactions with patients attending a specialist memory clinic. "Gold standard" diagnoses were made independently of CA findings by a multi-disciplinary team based on clinical assessment, neuropsychological testing and brain imaging. Results: Two discrete conversational profiles for patients with memory complaints emerged, including (i) who attends the clinic (i.e., whether or not patients are accompanied), and (ii) patients' responses to neurologists' questions about memory problems, such as difficulties with compound questions and providing specific and elaborated examples and frequent "I don't know" responses. Conclusion: Specific communicative difficulties are characteristic of the interaction patterns of patients with a neurodegenerative pathology. Those difficulties are manifest in memory clinic interactions with neurologists, thereby helping to differentiate patients with dementia from those with FMD. Practical implications: Our findings demonstrate that conversational profiles based on patients' contributions to memory clinic encounters have diagnostic potential to assist the screening and referral process from primary care, and the diagnostic service in secondary care

Effect of long-term corticosterone implants on growth and immune function in juvenile alligators, Alligator mississippiensis

ABSTRACT Sixty juvenile alligators were implanted subcutaneously with slow release pellets of corticosterone or placebo. Alligators were divided into five different groups such that each group received a different dose. A blood sample was taken prior to and 4 days after the implants were in place to measure hormone levels. Additional blood samples were collected at 1 month and 3 months. At 4 days corticosterone levels ranged from 3,400 ng/ml in the group treated with the high dose to 40 ng/ml in the group implanted with the low dose. The extremely high dose caused 40% mortality within 4 weeks. It was evident that the pellets did not release the hormone for the expected 90 days. Circulating levels of corticosterone were back to baseline levels by 3 months. Hormone levels achieved at 4 days were a reliable predictor of subsequent growth. Rate of growth was negatively correlated with plasma corticosterone at 4 days (r 2 = 0.711) and at 1 month (r 2 = 0.544) posttreatment. Differential white blood cell counts performed after 1 month of treatment showed a clear effect of the implant. Alligators treated with corticosterone had decreased percentages of lymphocytes, eosinophils, and basophils and had a higher heterophil/lymphocyte (H/L) ratio than the placebo group. Furthermore, histological examination of the spleen revealed a significant depletion of lymphoid cells in alligators treated with the highest dose of hormone. The results from this study demonstrate that exogenous corticosterone can mimic the effects of prolonged stress in juvenile alligators. J. Exp. Zool. 279:156-162, 1997. © 1997 Studies of chronic stress in reptiles have demonstrated that elevated plasma corticosterone levels are associated with reproductive failure, immune suppression, and a reduction in or lack of growth (Lance, '94). It is well known that excessive levels of glucocorticoids suppress the immune system in mammals and can cause muscle breakdown and inhibit new bone formation and linear skeletal growth (Orth et al., '92). However, corticosterone's role in inhibiting growth in reptiles has not been substantiated thus far. Several studies have correlated elevated corticosterone levels with decreased growth in reptiles. A study by Elsey et al. ('90) showed that elevated plasma corticosterone levels were correlated with a reduction in growth in juvenile alligators stressed by crowding. In male green iguanas, plasma testosterone was positively correlated and plasma corticosterone level was negatively correlated with body mass and aggressive display frequency (Pratt et al., '92). Osmotically stressed juvenile alligators experienced a dramatic increase in corticosterone over a 5 week period which was correlated with lack of growth (Morici, '96). In addition to growth inhibition, immune suppression and endocrine alterations were also noted in these studies. Stress-induced immune suppression is well documented in fish (Pickering, '84; Ellsaesser and Clem, '87), birds (Siegel, '80), and mammals (Orth et al., '92), but there is little information available for reptiles, particularly the crocodilians. Therefore, this study was initiated to evaluate the long-term effects of corticosterone implants on growth, the immune response, and the endocrine system in the alligator. In this study we demonstrate that corticosterone alone, in the absence of an external stressor, suppresses growth and the immune system in juvenile alligators

Cross-sections for heavy atmospheres: H₂O continuum

Most of the exoplanets detected up to now transit in front of their host stars, allowing for the generation of transmission spectra; the study of exoplanet atmospheres relies heavily upon accurate analysis of these spectra. Recent discoveries mean that the study of atmospheric signals from low-mass, temperate worlds are becoming increasingly common. The observed transit depth in these planets is small and more difficult to analyze. Analysis of simulated transmission spectra for two small, temperate planets (GJ 1214 b and K2-18 b) is presented, giving evidence for significant differences in simulated transit depth when the water vapor continuum is accounted for when compared to models omitting it. These models use cross-sections from the CAVIAR lab experiment for the water self-continuum up to 10,000 cm−1; these cross-sections exhibit an inverse relationship with temperature, hence lower-temperature atmospheres are the most significantly impacted. Including the water continuum strongly affects transit depths, increasing values by up to 60 ppm, with the differences for both planets being detectable with the future space missions Ariel and JWST. It is imperative that models of exoplanet spectra move toward adaptive cross-sections, increasingly optimized for H2O-rich atmospheres. This necessitates including absorption contribution from the water vapor continuum into atmospheric simulations

The Perspectives of Lagos Healthcare Leaders on Faith-Institution Involvement in Hypertension Health

BACKGROUND: Hypertension is an important challenge for the Nigerian healthcare system and multiple stakeholder mitigation is imperative. Faith institution mitigation is evolving but the opinion of healthcare leaders on their involvement in hypertension remains an important gap. OBJECTIVE: To explore the perspectives of a cross-section of leaders of healthcare institutions in Lagos (Nigeria) on faith institution-facilitated hyper tension inter vention against the background of current practice. METHODS: Attempts were made to recruit 152 healthcare institution leaders who were contacted using electronic mails, telephone conversations, institutional social media communication, institutions' web-mails and other contacts. The views of consenting leaders were gathered using an exploratory questionnaire survey, and analysed. RESULTS: The views of 23 leaders from the variety of institutions were that most (60%) hypertension cases were diagnosed during emergency presentations; and the public's hypertension health knowledge remains generally inadequate. Hypertension information dissemination was mostly verbal rather than in written/print form. Basic resources are deployed in hypertension management. There was majority support for collaboration in hypertension health promotion (90.0%), blood pressure screening (95.7%) and hypertension referral (95.5%). Fewer institutions had the resources to support hypertension health promotion (55.0%) and blood pressure screening (42.1%) compared to hypertension referral (90.9%). CONCLUSION: There is good support for faith institution involvement in hypertension health, with a particular interest in and capacity for health system referral. Deploying scarce resources to collaborate may be challenging. However, collaboration and better resources could improve hypertension prevention and management. Further work is needed for context specific innovation so faith institutions can contribute to hypertension health

Improving the quality of care of children in community clinics: an intervention and evaluation in Bangladesh.

Community health care providers (CHCPs) in 40 rural community clinics of Comilla district, Bangladesh, were trained using a newly developed case-management job aid based on the World Health Organization Integrated Management of Childhood Illness and a communication guide.To assess 1) the change in knowledge of the CHCPs after training; 2) the absolute quality of care provided by the CHCPs (determined as the proportion of children aged <5 years [under-fives] correctly diagnosed, treated and referred); and 3) the consultation behaviour of the CHCPs.Change in knowledge was assessed by tests pre-and post-training. The quality of care was determined by reassessments at the clinic exit by a medical officer, without a baseline comparison. Consultation behaviour was assessed through direct observation. The study was performed during 2014-2015.The mean standard knowledge score of the CH-CPs increased from 19 to 25 (P < 0.001). Of 1490 under-fives examined, 91% were correctly diagnosed, 86% were correctly treated and 99.5% received a correct referral decision. The CHCPs performed well on most of the measures of good communication, although one third did not explain the diagnosis and treatment to patients.The training was effective in changing knowledge. The CHCPs applied the knowledge gained and provided good quality care. Following these results, the Bangladesh Ministry of Health and Family Welfare has scaled up the training nationwide. The lessons learnt should be useful for other countries

"Of Mice and Measures": A Project to Improve How We Advance Duchenne Muscular Dystrophy Therapies to the Clinic

A new line of dystrophic mdx mice on the DBA/2J (D2) background has emerged as a candidate to study the efficacy of therapeutic approaches for Duchenne muscular dystrophy (DMD). These mice harbor genetic polymorphisms that appear to increase the severity of the dystropathology, with disease modifiers that also occur in DMD patients, making them attractive for efficacy studies and drug development. This workshop aimed at collecting and consolidating available data on the pathological features and the natural history of these new D2/mdx mice, for comparison with classic mdx mice and controls, and to identify gaps in information and their potential value. The overall aim is to establish guidance on how to best use the D2/mdx mouse model in preclinical studies

Self-similar Solutions to a Kinetic Model for Grain Growth

We prove the existence of self-similar solutions to the Fradkov model for two-dimensional grain growth, which consists of an infinite number of nonlocally coupled transport equations for the number densities of grains with given area and number of neighbours (topological class). For the proof we introduce a finite maximal topological class and study an appropriate upwind-discretization of the time dependent problem in self-similar variables. We first show that the resulting finite dimensional differential system has nontrivial steady states. Afterwards we let the discretization parameter tend to zero and prove that the steady states converge to a compactly supported self-similar solution for a Fradkov model with finitely many equations. In a third step we let the maximal topology class tend to infinity and obtain self-similar solutions to the original system that decay exponentially. Finally, we use the upwind discretization to compute self-similar solutions numerically.Comment: 25 pages, several figure