Value and effectiveness of National Immunization Technical Advisory Groups in low- and middle-income countries : A qualitative study of global and national perspectives

© The Author(s) 2019. Published by Oxford University Press in association with The London School of Hygiene and Tropical Medicine.The Global Vaccine Action Plan proposes that every country establish or have access to a National Immunization Technical Advisory Group (NITAG) by 2020. The NITAG role is to produce evidence-informed recommendations that incorporate local context, to guide national immunization policies and practice. This study aimed to explore the value and effectiveness of NITAGs in low- and middle-income countries (LMICs), identifying areas in which NITAGs may require further support to improve their functionality and potential barriers to global investment. A multi-methods study design was used, comprising 134 semi-structured interviews and 82 literature review sources that included 38 countries. Interviews were conducted with 53 global/regional and 81 country-level participants able to provide insight into NITAG effectiveness, including NITAG members, national immunization programme staff, and global agency representatives (e.g. the World Health Organisation, the Bill and Melinda Gates Foundation, Gavi the Vaccine Alliance). The review, including published and unpublished sources on NITAGs in LMICs, was conducted to supplement and corroborate interview findings. Data were analysed thematically. NITAGs were described as valuable in promoting evidence-informed vaccination decision-making, with NITAG involvement enhancing national immunization programme strength and sustainability. Challenges to NITAG effectiveness included: (1) unreliable funding; (2) insufficient diversity of member expertise; (3) inadequate conflicts of interest management procedures; (4) insufficient capacity to access and use evidence; (5) lack of transparency; and (6) limited integration with national decision-making processes that reduced the recognition and incorporation of NITAG recommendations. LMIC NITAGs have developed significantly in the past decade. Well-functioning NITAGs were trusted national resources that enhanced country ownership of immunization provision. However, many LMIC NITAGs require additional technical and funding support to strengthen quality and effectiveness, while maintaining impartiality and ensuring sufficient integration with national decision-making processes. Barriers to sustainable global support need to be addressed for LMIC NITAGs to both continue and develop further.Peer reviewedFinal Published versio

Metabolically active and polyploid renal tissues rely on graded cytoprotection to drive developmental and homeostatic stress resilience

Body tissues are frequently exposed to stress, from toxic byproducts generated during cellular metabolism through to infection or wounding. Although it is well-established that tissues respond to exogenous injury by rapidly upregulating cytoprotective machinery, how energetically demanding tissues – vulnerable to persistent endogenous insult – withstand stress is poorly understood. Here, we show that the cytoprotective factors Nrf2 and Gadd45 act within a specific renal cell subtype, the energetically and biosynthetically active ‘principal’ cells, to drive stress resilience during Drosophila renal development and homeostasis. Renal tubules lacking Gadd45 exhibit striking morphogenetic defects (with cell death, inflammatory infiltration and reduced ploidy) and accumulate significant DNA damage in post-embryonic life. In parallel, the transcription factor Nrf2 is active during periods of intense renal physiological activity, where it protects metabolically active renal cells from oxidative damage. Despite its constitutive nature, renal cytoprotective activity must be precisely balanced and sustained at modest sub-injury levels; indeed, further experimental elevation dramatically perturbs renal development and function. We suggest that tissues requiring long-term protection must employ restrained cytoprotective activity, whereas higher levels might only be beneficial if activated transiently pre-emptive to exogenous insult

A Qualitative Exploration of Existing Reflective Practices Used by Undergraduate Dental Students in Paediatric Dentistry

Background: Reflection is increasingly significant for dental students and professionals and is a continuing requirement of dental regulatory bodies. There is a paucity of evidence regarding how best to facilitate deep reflection for dental students. This study explored whether the use of clinical logbooks in undergraduate clinical attachments in Paediatric Dentistry was facilitating deep reflection. Methods: This qualitative study used individual interviews for data collection. This was conducted at the University of Sheffield with third year undergraduate dental students and clinical teaching staff. Interviews were immediately transcribed verbatim. A reflexive approach to thematic analysis was used to co-constitute the data, enabling the development of the thematic framework. Results: The sample compromised 10 students and 4 educators. Thematic analysis generated 4 key themes: understanding of reflection, preparation for reflection, importance of learning through experience, and suggestions for development. The findings indicated that students perceived that they were not being supported in engaging in deep reflection by the use of a clinical logbook and that greater preparation for reflection would be beneficial. Conclusions: The current study revealed that using clinical logbooks during clinical attachments in Paediatric Dentistry was not facilitating deep reflection. Further research is required to explore how deep reflection can be facilitated for undergraduate dental students undertaking clinical learning

A Qualitative Exploration of Existing Reflective Practices Used by Undergraduate Dental Students in Paediatric Dentistry

Background: Reflection is increasingly significant for dental students and professionals and is a continuing requirement of dental regulatory bodies. There is a paucity of evidence regarding how best to facilitate deep reflection for dental students. This study explored whether the use of clinical logbooks in undergraduate clinical attachments in Paediatric Dentistry was facilitating deep reflection. Methods: This qualitative study used individual interviews for data collection. This was conducted at the University of Sheffield with third year undergraduate dental students and clinical teaching staff. Interviews were immediately transcribed verbatim. A reflexive approach to thematic analysis was used to co-constitute the data, enabling the development of the thematic framework. Results: The sample compromised 10 students and 4 educators. Thematic analysis generated 4 key themes: understanding of reflection, preparation for reflection, importance of learning through experience, and suggestions for development. The findings indicated that students perceived that they were not being supported in engaging in deep reflection by the use of a clinical logbook and that greater preparation for reflection would be beneficial. Conclusions: The current study revealed that using clinical logbooks during clinical attachments in Paediatric Dentistry was not facilitating deep reflection. Further research is required to explore how deep reflection can be facilitated for undergraduate dental students undertaking clinical learning

Interpreting the Ionization Sequence in Star-Forming Galaxy Emission-Line Spectra

High ionization star forming (SF) galaxies are easily identified with strong emission line techniques such as the BPT diagram, and form an obvious ionization sequence on such diagrams. We use a locally optimally emitting cloud model to fit emission line ratios that constrain the excitation mechanism, spectral energy distribution, abundances and physical conditions along the star-formation ionization sequence. Our analysis takes advantage of the identification of a sample of pure star-forming galaxies, to define the ionization sequence, via mean field independent component analysis. Previous work has suggested that the major parameter controlling the ionization level in SF galaxies is the metallicity. Here we show that the observed SF- sequence could alternatively be interpreted primarily as a sequence in the distribution of the ionizing flux incident on gas spread throughout a galaxy. Metallicity variations remain necessary to model the SF-sequence, however, our best models indicate that galaxies with the highest and lowest observed ionization levels (outside the range -0.37 < log [O III]/H\b{eta} < -0.09) require the variation of an additional physical parameter other than metallicity, which we determine to be the distribution of ionizing flux in the galaxy.Comment: 41 pages, 17 figures, 9 tables, accepted to MNRA

The role of National Immunisation Technical Advisory Groups (NITAGs) in strengthening national vaccine decision-making: A comparative case study of Armenia, Ghana, Indonesia, Nigeria, Senegal and Uganda.

INTRODUCTION: Improving evidence informed decision-making in immunisation is a global health priority and many low and middle-income countries have established National Immunisation Technical Advisory Groups (NITAGs) as independent technical advisory bodies for this purpose. NITAG development and strengthening has received financial and technical support over the past decade, but relatively little evaluation. This study examined NITAGs in six low and middle-income countries (i.e. Armenia, Ghana, Indonesia, Nigeria, Senegal, Uganda), to examine functionality, quality of recommendation development, and integration with national decision-making bodies and processes. METHODS: A mixed-method case-series design, used semi-structured interviews, NITAG meeting observations, and document review. Data were analysed thematically. RESULTS: Five NITAGs had been legally established with terms of reference and appeared well functioning, with Ghana's in development. All NITAGs had standard operating procedures and nomination procedures to ensure a range of expertise, generally comprising 10-15 core, 1-5 secretariat, and several ex-officio members. Aside from economics, NITAGs reported a wide range of member expertise. Newer NITAGs had particular concerns about funding. Four used formal conflict of interest procedures, although some commented that implications were not always understood. NITAGs valued local data, and limited evidence suggested NITAG presence might reinforce data production through surveillance and local research studies. All observed meetings demonstrated due process and evidence-based decision-making processes were generally followed, with a critical role played by working-group data syntheses and assessments. NITAGs were seen as well integrated with ministry of health (MoH) decision-making and MoH interviewees were positive about NITAG contributions, indicating NITAGs had an important role. Collaboration with other bodies was more limited, but mitigated by NITAG members' cross-membership in other bodies. CONCLUSIONS: NITAGs have an important and valued role within national immunisation decision-making. However, their position remains insecure, with the need for sustainable technical and financial support

“Better workplaces are good for everyone”: An interview with Natalie Grant of SMTJ about motherhood, working in television and the Covid-19 pandemic

Natalie Grant is a freelance series producer primarily working in entertainment and reality television and codirector of Share My Telly Job (SMTJ), an organisation that exists to promote job-sharing and the normalisation of other forms of flexible working in the UK television and film industry, such as condensed hours and part-time work, in order to encourage better equality, diversity and inclusion. In this interview by Helen Kennedy and Jack Newsinger, held via email in December 2021, Grant talks about her experiences as a mother working in television, what led to her becoming a campaigner, and how more flexible kinds of work can promote greater equality and diversity in the television industry workforce

Co-creation to Develop Interventions to Facilitate Deep Reflection for Dental Students

Background: Deep reflective practice is important in healthcare education to allow students to explore emotions associated with the learning experience, access deeper learning and develop their personal and professional identity. Previous research demonstrated that the current methods of reflective practice using logbooks at the end of a clinical session to facilitate reflection within this setting were viewed as suboptimal by staff and student users. To address this problem co-creation, or a ‘students as partners’ approach, was used to develop and implement a comprehensive intervention to facilitate deep reflection for undergraduate dental students. This included the production of educational resources, and development of an online safe space to reflect.Approach: In this paper we discuss the process of using co-creation with undergraduate dental students as a research methodology to successfully produce curricular change with respect to reflective practice by involving the voice and experience of student partners. These student partners were part of a team that included researchers and teaching staff and worked with other stakeholders within the institution within a wider team.Evaluation: This paper demonstrates the positive benefits of using co-creation with undergraduate dental students for students such as increased confidence, developing professional and personal skills and impacting meaningful change.Reflection: For researchers and educators, the process gave motivation and enjoyment in curricular development to address pedagogical problems and ensured that the developed intervention was sustainable and appropriate. The paper discusses benefits and challenges of co-creation to develop curricular change. This co-creation approach is recommended for solving similar problems in healthcare education

Measuring the health systems impact of disease control programmes: a critical reflection on the WHO building blocks framework.

BACKGROUND: The WHO health systems Building Blocks framework has become ubiquitous in health systems research. However, it was not developed as a research instrument, but rather to facilitate investments of resources in health systems. In this paper, we reflect on the advantages and limitations of using the framework in applied research, as experienced in three empirical vaccine studies we have undertaken. DISCUSSION: We argue that while the Building Blocks framework is valuable because of its simplicity and ability to provide a common language for researchers, it is not suitable for analysing dynamic, complex and inter-linked systems impacts. In our three studies, we found that the mechanical segmentation of effects by the WHO building blocks, without recognition of their interactions, hindered the understanding of impacts on systems as a whole. Other important limitations were the artificial equal weight given to each building block and the challenge in capturing longer term effects and opportunity costs. Another criticism is not of the framework per se, but rather how it is typically used, with a focus on the six building blocks to the neglect of the dynamic process and outcome aspects of health systems.We believe the framework would be improved by making three amendments: integrating the missing "demand" component; incorporating an overarching, holistic health systems viewpoint and including scope for interactions between components. If researchers choose to use the Building Blocks framework, we recommend that it be adapted to the specific study question and context, with formative research and piloting conducted in order to inform this adaptation. SUMMARY: As with frameworks in general, the WHO Building Blocks framework is valuable because it creates a common language and shared understanding. However, for applied research, it falls short of what is needed to holistically evaluate the impact of specific interventions on health systems. We propose that if researchers use the framework, it should be adapted and made context-specific