The potential impact of flooding on confined animal feeding operations in eastern North Carolina.

Thousands of confined animal feeding operations (CAFOs) have been constructed in eastern North Carolina. The fecal waste pit and spray field waste management systems used by these operations are susceptible to flooding in this low-lying region. To investigate the potential that flood events can lead to environmental dispersion of animal wastes containing numerous biologic and chemical hazards, we compared the geographic coordinates of 2,287 CAFOs permitted by the North Carolina Division of Water Quality (DWQ) with estimates of flooding derived from digital satellite images of eastern North Carolina taken approximately 1 week after Hurricane Floyd dropped as much as 15-20 inches of rain in September 1999. Three cattle, one poultry, and 237 swine operations had geographic coordinates within the satellite-based flooded area. DWQ confirmed 46 operations with breached or flooded fecal waste pits in the same area. Only 20 of these 46 CAFOs were within the satellite-based estimate of the inundated area. CAFOs within the satellite-based flood area were located in 132 census block groups with a population of 171,498 persons in the 2000 census. African Americans were more likely than whites to live in areas with flooded CAFOs according to satellite estimates, but not according to DWQ reports. These areas have high poverty rates and dependence on wells for drinking water. Our analysis suggests that flood events have a significant potential to degrade environmental health because of dispersion of wastes from industrial animal operations in areas with vulnerable populations

The community health worker as service extender, cultural broker and social change agent: a critical interpretive synthesis of roles, intent and accountability

This paper is a critical interpretive synthesis of community health workers (CHWs) and accountability in low-income and middle-income countries. The guiding questions were: What factors promote or undermine CHWs as accountability agents? (and) Can these factors be intentionally fostered or suppressed to impel health system accountability? We conducted an iterative search that included articles addressing the core issue of CHWs and accountability, and articles addressing ancillary issues that emerged in the initial search, such as 'CHWs and equity.' CHWs are intended to comprise a 'bridge' between community members and the formal health system. This bridge function is described in three key ways: service extender, cultural broker, social change agent. We identified several factors that shape the bridging function CHWs play, and thus, their role in fomenting health system accountability to communities, including the local political context, extent and nature of CHW interactions with other community-based structures, health system treatment of CHWs, community perceptions of CHWs, and extent and type of CHW unionisation and collectivisation. Synthesising these findings, we elaborated several analytic propositions relating to the self-reinforcing nature of the factors shaping CHWs' bridging function; the roles of local and national governance; and the human resource and material capacity of the health system. Importantly, community embeddedness, as defined by acceptability, social connections and expertise, is a crucial attribute of CHW ability to foment local government accountability to communities

Community and health system intervention to reduce disrespect and abuse during childbirth in Tanga Region, Tanzania: A comparative before-and-after study

Background Abusive treatment of women during childbirth has been documented in low-resource countries and is a deterrent to facility utilization for delivery. Evidence for interventions to address women’s poor experience is scant. We assessed a participatory community and health system intervention to reduce the prevalence of disrespect and abuse during childbirth in Tanzania. Methods and findings We used a comparative before-and-after evaluation design to test the combined intervention to reduce disrespect and abuse. Two hospitals in Tanga Region, Tanzania were included in the study, 1 randomly assigned to receive the intervention. Women who delivered at the study facilities were eligible to participate and were recruited upon discharge. Surveys were conducted at baseline (December 2011 through May 2012) and after the intervention (March through September 2015). The intervention consisted of a client service charter and a facility-based, quality-improvement process aimed to redefine norms and practices for respectful maternity care. The primary outcome was any self-reported experiences of disrespect and abuse during childbirth. We used multivariable logistic regression to estimate a difference-in-difference model. At baseline, 2,085 women at the 2 study hospitals who had been discharged from the maternity ward after delivery were invited to participate in the survey. Of these, 1,388 (66.57%) agreed to participate. At endline, 1,680 women participated in the survey (72.29% of those approached). The intervention was associated with a 66% reduced odds of a woman experiencing disrespect and abuse during childbirth (odds ratio [OR]: 0.34, 95% CI: 0.21–0.58, p < 0.0001). The biggest reductions were for physical abuse (OR: 0.22, 95% CI: 0.05–0.97, p = 0.045) and neglect (OR: 0.36, 95% CI: 0.19–0.71, p = 0.003). The study involved only 2 hospitals in Tanzania and is thus a proof-of-concept study. Future, larger-scale research should be undertaken to evaluate the applicability of this approach to other settings. Conclusions After implementation of the combined intervention, the likelihood of women’s reports of disrespectful treatment during childbirth was substantially reduced. These results were observed nearly 1 year after the end of the project’s facilitation of implementation, indicating the potential for sustainability. The results indicate that a participatory community and health system intervention designed to tackle disrespect and abuse by changing the norms and standards of care is a potential strategy to improve the treatment of women during childbirth at health facilities. The trial is registered on the ISRCTN Registry, ISRCTN 48258486

Studying moderators of implementation: analysis from an intervention to reduce disrespect and abuse in facility-based childbirth

Background: Across the globe, women who deliver in health facilities report experiencing disrespect and abuse (D&A). In low- and middle-income countries, D&A is particularly catastrophic because it may cause women to opt against facility delivery, as well as violate their human rights. D&A is likely a frontline manifestation of multi-level problems in complex health systems; yet efforts to address D&A have typically focused on micro-levels - either health providers’ ethics or users’ demand for quality care. These have rarely achieved sustainable implementation mirroring clinical quality improvement challenges. Implementation science holds promise for investigating these challenges. The Consolidated Framework for Implementation Research (CFIR) assembles constructs from across the literature that can guide inquiry. Materials and methods: The Staha Project studies the magnitude and dimensions of D&A, and is testing mechanisms for its mitigation. It is based in two Tanzanian districts, with one assigned to intervention. Implementation is conducted by four facilities, catchment communities and local leadership. Implementation research includes patient and provider satisfaction surveys, observations, reports and qualitative interviews. Relevant CFIR constructs were selected to develop the lines of inquiry and as themes for qualitative analysis adapted iteratively based on data. We conducted descriptive analyses of quantitative data. Results: The intervention was developed through a participatory process grounded in baseline research to address meso- and micro-level drivers at the district level. A change process was elaborated including activation of a client service charter and a facility-based change process. Mutuality of respect emerged as the underlying value for the process. Results from the planning process and the first year of implementation will be presented using CFIR constructs. These will include findings related to the characteristics of the intervention, inner and outer settings, individual implementers and the process. Conclusions: The CFIR was a useful tool to establish lines of inquiry and frame analysis. Ongoing analysis permitted identification of areas for improvement. We found the strongest constructs were regarding the intervention, the individual, and the inner setting characteristics. The outer setting construct could be further developed, especially for interventions that go beyond health facilities

Community health workers and accountability: Reflections from an international "think-in"

Community health workers (CHWs) are frequently put forward as a remedy for lack of health system capacity, including challenges associated with health service coverage and with low community engagement in the health system, and expected to enhance or embody health system accountability. During a ‘think in’, held in June of 2017, a diverse group of practitioners and researchers discussed the topic of CHWs and their possible roles in a larger “accountability ecosystem.” This jointly authored commentary resulted from our deliberations. While CHWs are often conceptualized as cogs in a mechanistic health delivery system, at the end of the day, CHWs are people embedded in families, communities, and the health system. CHWs’ social position and professional role influence how they are treated and trusted by the health sector and by community members, as well as when, where, and how they can exercise agency and promote accountability. To that end, we put forward several propositions for further conceptual development and research related to the question of CHWs and accountability.publishedVersio

Community health workers and accountability: reflections from an international “think-in”

Community health workers (CHWs) are frequently put forward as a remedy for lack of health system capacity, including challenges associated with health service coverage and with low community engagement in the health system, and expected to enhance or embody health system accountability. During a ‘think in’, held in June of 2017, a diverse group of practitioners and researchers discussed the topic of CHWs and their possible roles in a larger “accountability ecosystem.” This jointly authored commentary resulted from our deliberations. While CHWs are often conceptualized as cogs in a mechanistic health delivery system, at the end of the day, CHWs are people embedded in families, communities, and the health system. CHWs’ social position and professional role influence how they are treated and trusted by the health sector and by community members, as well as when, where, and how they can exercise agency and promote accountability. To that end, we put forward several propositions for further conceptual development and research related to the question of CHWs and accountability

The CA repeat marker D17S791 islocated within 40 kb of the WNT3 gene on chromosome 17q

Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/30428/1/0000049.pd

HDAC9 is implicated in atherosclerotic aortic calcification and affects vascular smooth muscle cell phenotype.

Aortic calcification is an important independent predictor of future cardiovascular events. We performed a genome-wide association meta-analysis to determine SNPs associated with the extent of abdominal aortic calcification (n = 9,417) or descending thoracic aortic calcification (n = 8,422). Two genetic loci, HDAC9 and RAP1GAP, were associated with abdominal aortic calcification at a genome-wide level (P &lt; 5.0 × 10-8). No SNPs were associated with thoracic aortic calcification at the genome-wide threshold. Increased expression of HDAC9 in human aortic smooth muscle cells promoted calcification and reduced contractility, while inhibition of HDAC9 in human aortic smooth muscle cells inhibited calcification and enhanced cell contractility. In matrix Gla protein-deficient mice, a model of human vascular calcification, mice lacking HDAC9 had a 40% reduction in aortic calcification and improved survival. This translational genomic study identifies the first genetic risk locus associated with calcification of the abdominal aorta and describes a previously unknown role for HDAC9 in the development of vascular calcification

Serum 25-Hydroxyvitamin D and Risk of Lung Cancer in Male Smokers: A Nested Case-Control Study

A role for vitamin D in cancer risk reduction has been hypothesized, but few data exist for lung cancer. We investigated the relationship between vitamin D status, using circulating 25-hydroxyvitamin D [25(OH)D], and lung cancer risk in a nested case-control study within the Alpha-Tocopherol, Beta-Carotene Cancer Prevention Study of Finnish male smokers.Lung cancer cases (n = 500) were randomly selected based on month of blood collection, and 500 controls were matched to them based on age and blood collection date. Odds ratios (ORs) and 95% confidence intervals (CIs) were calculated using multivariate-adjusted conditional logistic regression. To account for seasonal variation in 25(OH)D concentrations, season-specific and season-standardized quintiles of 25(OH)D were examined, and models were also stratified on season of blood collection (darker season = November-April and sunnier season = May-October). Pre-determined, clinically-defined cutpoints for 25(OH)D and 25(OH)D as a continuous measure were also examined.Overall, 25(OH)D was not associated with lung cancer. Risks were 1.08 (95% CI 0.67-1.75) and 0.83 (95% CI 0.53-1.31) in the highest vs. lowest season-specific and season-standardized quintiles of 25(OH)D, respectively, and 0.91 (95% CI 0.48-1.72) for the ≥75 vs. <25 nmol/L clinical categories. Inverse associations were, however, suggested for subjects with blood collections from November-April, with ORs of 0.77 (95% CI 0.41-1.45, p-trend = 0.05) and 0.65 (95% CI 0.37-1.14, p-trend = 0.07) in the highest vs. lowest season-specific and season-standardized quintiles of 25(OH)D, respectively, and 0.61 (95% CI 0.24-1.52, p-trend = 0.01) for ≥75 vs. <25 nmol/L. We also found 11% lower risk for a 10 nmol/L increase in 25(OH)D in the darker season based on the continuous measure (OR = 0.89, 95% CI 0.81-0.98, p = 0.02).In this prospective study of male smokers, circulating 25(OH)D was not associated with lung cancer risk overall, although inverse associations were suggested among those whose blood was drawn during darker months