From the Ground Up: Strengthening Health Systems at District Level (Introduction)

This supplement introduces the African Health Initiative (AHI), a research program comprised of five unique district health system-strengthening activities in Ghana, Mozambique, Rwanda, Tanzania, and Zambia that beganin 2009. This supplement should be of interest to all engaged in improving delivery of district primary health care -- whether ministries of health, service providers, funders, or those who evaluate complex interventions. The five AHI projects, known as Population Health Implementation and Training (PHIT) Partnerships, are funded by the Doris Duke Charitable Foundation (DDCF) with a common goal: to produce significant, measureable health improvements in a defined geographic area over a five to seven year grant period.With the partnerships in their fourth year of funding, it is now possible to capture lessons learned in project design and implementation. Evaluation of the African Health Initiative's impact on population health, including mortality, however, mustawait the conclusion of the grant period

Are overwhelmed health systems an inevitable consequence of covid-19? Experiences from China, Thailand, and New York State.

Drawing on international experiences, in particular lessons from China, Thailand and New York State, USA, Viroj Tangcharoensathien and colleagues argue that immediate, extensive and effective responses to contain the local transmission of corona virus at the very early stages of an epidemic can prevent health systems from disruption and from being overwhelmed

Changes in energy content of lunchtime purchases from fast food restaurants after introduction of calorie labelling: cross sectional customer surveys

Objective To assess the impact of fast food restaurants adding calorie labelling to menu items on the energy content of individual purchases

Effectiveness of a large-scale distribution programme of free nicotine patches: a prospective evaluation

Abstract BACKGROUND: After an increase in cigarette taxes and implementation of smoke-free workplace legislation, the New York City Department of Health and Mental Hygiene, the New York State Department of Health, and the Roswell Park Cancer Institute undertook large-scale distribution of free nicotine replacement therapy (NRT). We did a 6 month follow-up survey to assess the success of this programme in improving smoking cessation on a population basis. METHODS: 34,090 eligible smokers who phoned a toll-free quitline were sent a 6-week course of nicotine patches (2 weeks each of 21 mg, 14 mg, and 7 mg per day). Brief follow-up counselling calls were attempted. At 6 months after treatment, we assessed smoking status of 1305 randomly sampled NRT recipients and a non-randomly selected comparison group of eligible smokers who, because of mailing errors, did not receive the treatment. NRT recipients were compared with local survey-derived data for heavy smokers in New York City. FINDINGS: An estimated 5% of all adults in New York City who smoked ten cigarettes or more daily received NRT; most (64%) recipients were non-white, foreign-born, or resided in a low-income neighbourhood. Of individuals contacted at 6 months, more NRT recipients than comparison group members successfully quit smoking (33%vs 6%, p\u3c0.0001), and this difference remained significant after adjustment for demographic factors and amount smoked (odds ratio 8.8, 95% CI 4.4-17.8). Highest quit rates were associated with those who were foreign born (87 [39%]), older than 65 years (40 [47%]), and smoked less than 20 cigarettes per day (116 [35%]). Those who received a counselling call were more likely to stop smoking than those who did not (246 [38%] vs 189 [27%], p=0.001). With the conservative assumption that every 6-month follow-up survey non-respondent continued to smoke, the stop rate among NRT recipients was 20%. At least 6038 successful quits were attributable to NRT receipt, and cost was 464 US dollars per quit. INTERPRETATION: Easy access to cessation medication for diverse populations could help many more smokers to stop

A study of women\u27s preferences regarding the formulation of over-the-counter vaginal spermicides

There is an urgent need for safe, effective, and acceptable vaginal barrier methods for the prevention of sexually transmitted diseases (STDs), including HIV, and a variety of existing spermicides have the potential to be used for both prevention of STDs and unwanted pregnancy. Unfortunately, very little is known about formulation preferences and the desirable characteristics of vaginal preparations among the diverse populations of women who would potentially use these products. In this study, we explored vaginal spermicidal preparations containing nonoxynol-9 and the characteristics that influence user preferences for three formulations, as well as the risk of vaginal and cervical irritation associated with low-to-moderate use of products containing nonoxynol-9. The report recommends that formulation preferences of women be considered in the development and introduction of vaginal microbicides: the specific characteristics of vaginal products and their effect on sexual pleasure and communication will strongly determine the acceptability—and ultimately the use-effectiveness—of female-controlled STD-prevention methods

Impact of family networks on uptake of health interventions: evidence from a community-randomized control trial aimed at increasing HIV testing in South Africa

INTRODUCTION: While it is widely acknowledged that family relationships can influence health outcomes, their impact on the uptake of individual health interventions is unclear. In this study, we quantified how the efficacy of a randomized health intervention is shaped by its pattern of distribution in the family network. METHODS: The "Home-Based Intervention to Test and Start" (HITS) was a 2×2 factorial community-randomized controlled trial in Umkhanyakude, KwaZulu-Natal, South Africa, embedded in the Africa Health Research Institute's population-based demographic and HIV surveillance platform (ClinicalTrials.gov # NCT03757104). The study investigated the impact of two interventions: a financial micro-incentive and a male-targeted HIV-specific decision support programme. The surveillance area was divided into 45 community clusters. Individuals aged ≥15 years in 16 randomly selected communities were offered a micro-incentive (R50 [$3] food voucher) for rapid HIV testing (intervention arm). Those living in the remaining 29 communities were offered testing only (control arm). Study data were collected between February and November 2018. Using routinely collected data on parents, conjugal partners, and co-residents, a socio-centric family network was constructed among HITS-eligible individuals. Nodes in this network represent individuals and ties represent family relationships. We estimated the effect of offering the incentive to people with and without family members who also received the offer on the uptake of HIV testing. We fitted a linear probability model with robust standard errors, accounting for clustering at the community level. RESULTS: Overall, 15,675 people participated in the HITS trial. Among those with no family members who received the offer, the incentive's efficacy was a 6.5 percentage point increase (95% CI: 5.3-7.7). The efficacy was higher among those with at least one family member who received the offer (21.1 percentage point increase (95% CI: 19.9-22.3). The difference in efficacy was statistically significant (21.1-6.5 = 14.6%; 95% CI: 9.3-19.9). CONCLUSIONS: Micro-incentives appear to have synergistic effects when distributed within family networks. These effects support family network-based approaches for the design of health interventions

The appropriateness of core group interventions using presumptive periodic treatment among rural Zimbabwean women who exchange sex for gifts or money.

To map the characteristics of rural based sex workers in Zimbabwe with regard to demographics, mobility, behavior, HIV and sexually transmitted infection (STI) prevalence, to explore the appropriateness and feasibility of presumptive periodic treatment (PPT) for bacterial STIs as an HIV prevention intervention among these women, and to compare tolerability of 2 PPT regimens (1 g of azithromycin and 2 g of metronidazole+/-500 mg of ciprofloxacin). Five commercial farms and 2 mines in Mashonaland West, Zimbabwe. Three hundred sixty-three sex workers were recruited and completed a structured interviewer-administered questionnaire. Each participant had blood tested for antibody to HIV, herpes simplex virus 2 (HSV-2), and syphilis; urine tested for Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG); and a vaginal swab tested for Trichomonas vaginalis (TV). Women were randomly assigned to receive a single dose of 1 of 2 PPT regimens and then followed to assess rates of side effects and reinfection. The overall prevalence of antibody to HIV was 55.7% (95% confidence interval [CI]: 50.6-60.9) and that of HSV-2 was 80.8% (95% CI: 76.7-84.9). The prevalence of CT and NG was low (CT=1.7%, 95% CI: 0.3-3.0); (NG=1.9%, 95% CI: 0.5-3.4), with a much higher prevalence of TV (TV=19.3%, 95% CI: 15.2-23.4). Prevalence of CT, NG, and TV was appreciably reduced 1 month after PPT but rose to pretreatment levels at the 2- and 3-month visits. The rate of moderate or severe side effects after PPT was low, but it was higher in the women who received ciprofloxacin in addition to azithromycin and metronidazole (P=0.007). It was feasible to access women who reported exchanging money or gifts for sex in rural communities, although many of these women engaged in sex work only infrequently. The prevalence of bacterial STIs was low, suggesting that PPT may not be an appropriate intervention in this setting. Rapid reinfection after PPT suggests that this needs to be given at monthly intervals to reduce prevalence of STIs

Brain network adaptability across task states.

Activity in the human brain moves between diverse functional states to meet the demands of our dynamic environment, but fundamental principles guiding these transitions remain poorly understood. Here, we capitalize on recent advances in network science to analyze patterns of functional interactions between brain regions. We use dynamic network representations to probe the landscape of brain reconfigurations that accompany task performance both within and between four cognitive states: a task-free resting state, an attention-demanding state, and two memory-demanding states. Using the formalism of hypergraphs, we identify the presence of groups of functional interactions that fluctuate coherently in strength over time both within (task-specific) and across (task-general) brain states. In contrast to prior emphases on the complexity of many dyadic (region-to-region) relationships, these results demonstrate that brain adaptability can be described by common processes that drive the dynamic integration of cognitive systems. Moreover, our results establish the hypergraph as an effective measure for understanding functional brain dynamics, which may also prove useful in examining cross-task, cross-age, and cross-cohort functional change