The anatomy of exhumed river-channel belts: Bedform to belt‐scale river kinematics of the Ruby Ranch Member, Cretaceous Cedar Mountain Formation, Utah, USA

Many published interpretations of ancient fluvial systems have relied on observations of extensive outcrops of thick successions. This paper, in contrast, demonstrates that a regional understanding of palaeoriver kinematics, depositional setting and sedimentation rates can be interpreted from local sedimentological measurements of bedform and barform strata. Dune and bar strata, channel planform geometry and bed topography are measured within exhumed fluvial strata exposed as ridges in the Ruby Ranch Member of the Cretaceous Cedar Mountain Formation, Utah, USA. The ridges are composed of lithified stacked channel belts, representing at least five or six re‐occupations of a single‐strand channel. Lateral sections reveal well‐preserved barforms constructed of subaqueous dune cross‐sets. The topography of palaeobarforms is preserved along the top surface of the outcrops. Comparisons of the channel‐belt centreline to local palaeotransport directions indicate that channel planform geometry was preserved through the re‐occupations, rather than being obscured by lateral migration. Rapid avulsions preserved the state of the active channel bed and its individual bars at the time of abandonment. Inferred minimum sedimentation durations for the preserved elements, inferred from cross‐set thickness distributions and assumed bedform migration rates, vary within a belt from one to ten days. Using only these local sedimentological measurements, the depositional setting is interpreted as a fluvial megafan, given the similarity in river kinematics. This paper provides a systematic methodology for the future synthesis of vertical and planview data, including the drone‐equipped 2020 Mars Rover mission, to exhumed fluvial and deltaic strata

Can lay health workers support the management of hypertension? Findings of a cluster randomised trial in South Africa.

Introduction: In low/middle-income countries with substantial HIV and tuberculosis epidemics, health services often neglect other highly prevalent chronic conditions, such as hypertension, which as a result are poorly managed. This paper reports on a study to assess the effect on hypertension management of lay health workers (LHW) working in South African rural primary healthcare clinics to support the provision of integrated chronic care. Methods: A pragmatic cluster randomised trial with a process evaluation in eight rural clinics assessed the effect of adding two LHWs supporting nurses in providing chronic disease care in each intervention clinic over 18 months. Control clinics continued with usual care. The main outcome measure was the change in the difference of percentage of clinic users who had elevated cardiovascular risk associated with high blood pressure (BP) before and after the intervention, as measured by two cross-sectional population surveys. Results: There was no improvement in BP control among users of intervention clinics as compared with control clinics. However, the LHWs improved clinic functioning, including overall attendance, and attendance on the correct day. All clinics faced numerous challenges, including rapidly increasing number of users of chronic care, unreliable BP machines and cuffs, intermittent drug shortages and insufficient space. Conclusion: LHWs improved the process of providing care but improved BP control required improved clinical care by nurses which was compromised by large and increasing numbers of patients, the dominance of the vertically funded HIV programme and the poor standards of equipment in clinics. Trial registration number: ISRCTN12128227.The Nkateko study was funded by the UK Medical Research Council under the Global Alliance for Chronic Diseases (GACD) Programme

A cost-of-illness analysis of β-Thalassaemia major in children in Sri Lanka - experience from a tertiary level teaching hospital

Background Sri Lanka has a high prevalence of β-thalassaemia major. Clinical management is complex and long-term and includes regular blood transfusion and iron chelation therapy. The economic burden of β-thalassaemia for the Sri Lankan healthcare system and households is currently unknown. Methods A prevalence-based, cost-of-illness study was conducted on the Thalassaemia Unit, Department of Paediatrics, Kandy Teaching Hospital, Sri Lanka. Data were collected from clinical records, consultations with the head of the blood bank and a consultant paediatrician directly involved with the care of patients, alongside structured interviews with families to gather data on the personal costs incurred such as those for travel. Results Thirty-four children aged 2–17 years with transfusion dependent thalassaemia major and their parent/guardian were included in the study. The total average cost per patient year to the hospital was $US 2601 of which$US 2092 were direct costs and $US 509 were overhead costs. Mean household expenditure was$US 206 per year with food and transport per transfusion ($US 7.57 and$US 4.26 respectively) being the highest cost items. Nine (26.5%) families experienced catastrophic levels of healthcare expenditure (> 10% of income) in the care of their affected child. The poorest households were the most likely to experience such levels of expenditure. Conclusions β-thalassaemia major poses a significant economic burden on health services and the families of affected children in Sri Lanka. Greater support is needed for the high proportion of families that suffer catastrophic out-of-pocket costs

Jezero Crater, Mars, as a Compelling Site for Future In Situ Exploration

Jezero is a approximately 45 km diameter impact crater located in the Nili Fossae region of Mars. Jezero is an outstanding site to address key questions of ancient Mars climate, habitability, and volcanic history because: (a) It hosted an open-basin lake during the era of valley network formation [1,2], which ceased at approximately the Noachian-Hesperian boundary [3]. (b) It contains two delta deposits [1,4] with Fe/Mg-smectite and Mg-carbonate sediment [4-7] (the only exposure of lacus-trine shoreline carbonates seen so far on Mars). (c) The depositional environment and mineral assemblage of the delta are promising for the concentration and preservation of organic matter [5,8]. (d) The diverse geologic units in Jezero are in clear stratigraphic context [7]. The Jezero paleolake system has been thoroughly investigated at a variety of scales, including work on: the mineralogy of the delta deposits [4-6] and watershed [7], as well as the morphology and sedimentology of the basin [9] and delta deposits [1,4]. The geologic context of Jezero is also well-studied given the broad suite of alteration minerals exposed in the ancient stratigraphies of the Nili Fossae region [e.g., 6,10-13]. Here we present an overview of the units accessible for exploration in the Jezero basin, including questions and hypotheses that can be tested through analysis in situ and of returned samples. This is particularly timely given the upcoming Mars 2020 mission, for which Jezero is one of the final eight landing sites [14]. Primary science objectives for Mars 2020 are to: (1) characterize the geologic history of a site with "evidence of an astrobiologically-relevant ancient environment and geologic diversity"; (2) assess the habitability and "potential evidence of past life" in units with "high biosignature preservation potential"; and (3) cache scientifically compelling samples for potential return to Earth [15]

A new methodology for assessing health policy and systems research and analysis capacity in African universities.

BACKGROUND: The importance of health policy and systems research and analysis (HPSR+A) has been increasingly recognised, but it is still unclear how most effectively to strengthen the capacity of the different organisations involved in this field. Universities are particularly crucial but the expansive literature on capacity development has little to offer the unique needs of HPSR+A activity within universities, and often overlooks the pivotal contribution of capacity assessments to capacity strengthening. METHODS: The Consortium for Health Policy and Systems Analysis in Africa 2011-2015 designed and implemented a new framework for capacity assessment for HPSR+A within universities. The methodology is reported in detail. RESULTS: Our reflections on developing and conducting the assessment generated four lessons for colleagues in the field. Notably, there are currently no published capacity assessment methodologies for HPSR+A that focus solely on universities - we report a first for the field to initiate the dialogue and exchange of experiences with others. Second, in HPSR+A, the unit of assessment can be a challenge, because HPSR+A groups within universities tend to overlap between academic departments and are embedded in different networks. Third, capacity assessment experience can itself be capacity strengthening, even when taking into account that doing such assessments require capacity. CONCLUSIONS: From our experience, we propose that future systematic assessments of HPSR+A capacity need to focus on both capacity assets and needs and assess capacity at individual, organisational, and systems levels, whilst taking into account the networked nature of HPSR+A activity. A genuine partnership process between evaluators and those participating in an assessment can improve the quality of assessment and uptake of results in capacity strengthening

Behaviour change strategies for reducing blood pressure-related disease burden: findings from a global implementation research programme.

The Global Alliance for Chronic Diseases comprises the majority of the world's public research funding agencies. It is focussed on implementation research to tackle the burden of chronic diseases in low- and middle-income countries and amongst vulnerable populations in high-income countries. In its inaugural research call, 15 projects were funded, focussing on lowering blood pressure-related disease burden. In this study, we describe a reflexive mapping exercise to identify the behaviour change strategies undertaken in each of these projects.Using the Behaviour Change Wheel framework, each team rated the capability, opportunity and motivation of the various actors who were integral to each project (e.g. community members, non-physician health workers and doctors in projects focussed on service delivery). Teams then mapped the interventions they were implementing and determined the principal policy categories in which those interventions were operating. Guidance was provided on the use of Behaviour Change Wheel to support consistency in responses across teams. Ratings were iteratively discussed and refined at several group meetings.There was marked variation in the perceived capabilities, opportunities and motivation of the various actors who were being targeted for behaviour change strategies. Despite this variation, there was a high degree of synergy in interventions functions with most teams utilising complex interventions involving education, training, enablement, environmental restructuring and persuasion oriented strategies. Similar policy categories were also targeted across teams particularly in the areas of guidelines, communication/marketing and service provision with few teams focussing on fiscal measures, regulation and legislation.The large variation in preparedness to change behaviour amongst the principal actors across these projects suggests that the interventions themselves will be variably taken up, despite the similarity in approaches taken. The findings highlight the importance of contextual factors in driving success and failure of research programmes. Forthcoming outcome and process evaluations from each project will build on this exploratory work and provide a greater understanding of factors that might influence scale-up of intervention strategies

Universal health coverage from multiple perspectives: a synthesis of conceptual literature and global debates

Background: There is an emerging global consensus on the importance of universal health coverage (UHC), but no unanimity on the conceptual definition and scope of UHC, whether UHC is achievable or not, how to move towards it, common indicators for measuring its progress, and its long-term sustainability. This has resulted in various interpretations of the concept, emanating from different disciplinary perspectives. This paper discusses the various dimensions of UHC emerging from these interpretations and argues for the need to pay attention to the complex interactions across the various components of a health system in the pursuit of UHC as a legal human rights issue. Discussion: The literature presents UHC as a multi-dimensional concept, operationalized in terms of universal population coverage, universal financial protection, and universal access to quality health care, anchored on the basis of health care as an international legal obligation grounded in international human rights laws. As a legal concept, UHC implies the existence of a legal framework that mandates national governments to provide health care to all residents while compelling the international community to support poor nations in implementing this right. As a humanitarian social concept, UHC aims at achieving universal population coverage by enrolling all residents into health-related social security systems and securing equitable entitlements to the benefits from the health system for all. As a health economics concept, UHC guarantees financial protection by providing a shield against the catastrophic and impoverishing consequences of out-of-pocket expenditure, through the implementation of pooled prepaid financing systems. As a public health concept, UHC has attracted several controversies regarding which services should be covered: comprehensive services vs. minimum basic package, and priority disease-specific interventions vs. primary health care. Summary: As a multi-dimensional concept, grounded in international human rights laws, the move towards UHC in LMICs requires all states to effectively recognize the right to health in their national constitutions. It also requires a human rights-focused integrated approach to health service delivery that recognizes the health system as a complex phenomenon with interlinked functional units whose effective interaction are essential to reach the equilibrium called UHC

Process evaluation in the field: global learnings from seven implementation research hypertension projects in low-and middle-income countries

Background Process evaluation is increasingly recognized as an important component of effective implementation research and yet, there has been surprisingly little work to understand what constitutes best practice. Researchers use different methodologies describing causal pathways and understanding barriers and facilitators to implementation of interventions in diverse contexts and settings. We report on challenges and lessons learned from undertaking process evaluation of seven hypertension intervention trials funded through the Global Alliance of Chronic Diseases (GACD). Methods Preliminary data collected from the GACD hypertension teams in 2015 were used to inform a template for data collection. Case study themes included: (1) description of the intervention, (2) objectives of the process evaluation, (3) methods including theoretical basis, (4) main findings of the study and the process evaluation, (5) implications for the project, policy and research practice and (6) lessons for future process evaluations. The information was summarized and reported descriptively and narratively and key lessons were identified. Results The case studies were from low- and middle-income countries and Indigenous communities in Canada. They were implementation research projects with intervention arm. Six theoretical approaches were used but most comprised of mixed-methods approaches. Each of the process evaluations generated findings on whether interventions were implemented with fidelity, the extent of capacity building, contextual factors and the extent to which relationships between researchers and community impacted on intervention implementation. The most important learning was that although process evaluation is time consuming, it enhances understanding of factors affecting implementation of complex interventions. The research highlighted the need to initiate process evaluations early on in the project, to help guide design of the intervention; and the importance of effective communication between researchers responsible for trial implementation, process evaluation and outcome evaluation. Conclusion This research demonstrates the important role of process evaluation in understanding implementation process of complex interventions. This can help to highlight a broad range of system requirements such as new policies and capacity building to support implementation. Process evaluation is crucial in understanding contextual factors that may impact intervention implementation which is important in considering whether or not the intervention can be translated to other contexts