Healthcare equity analysis: applying the Tanahashi model of health service coverage to community health systems following devolution in Kenya

Background: Universal health coverage (UHC) is growing as a national political priority, within the context of recently devolved decision-making processes in Kenya. Increasingly voices within these discussions are highlighting the need for actions towards UHC to focus on quality of services, as well as improving coverage through expansion of national health insurance fund (NHIF) enrolment. Improving health equity is one of the most frequently described objectives for devolution of health services. Previous studies, however, highlight the complexity and unpredictability of devolution processes, potentially contributing to widening rather than reducing disparities. Our study applied Tanahashi's equity model (according to availability, accessibility, acceptability, contact with and quality) to review perceived equity of health services by actors across the health system and at community level, following changes to the priority-setting process at sub-national levels post devolution in Kenya.Methods: We carried out a qualitative study between March 2015 and April 2016, involving 269 key informant and in-depth interviews from different levels of the health system in ten counties and 14 focus group discussions with community members in two of these counties. Qualitative data were analysed using the framework approach.Results: Our findings reveal that devolution in Kenya has focused on improving the supply side of health services, by expanding the availability, geographic and financial accessibility of health services across many counties. However, there has been limited emphasis and investment in promoting the demand side, including restricted efforts to promote acceptability or use of services. Respondents perceived that the quality of health services has typically been neglected within priority-setting to date.Conclusions: If Kenya is to achieve universal health coverage for all citizens, then county governments must address all aspects of equity, including quality. Through application of the Tanahashi framework, we find that community health services can play a crucial role towards achieving health equity

Evaluation of Space Power Materials Flown on the Passive Optical Sample Assembly

Evaluating the performance of materials on the exterior of spacecraft is of continuing interest, particularly in anticipation of those applications that will require a long duration in low Earth orbit. The Passive Optical Sample Assembly (POSA) experiment flown on the exterior of Mir as a risk mitigation experiment for the International Space Station was designed to better understand the interaction of materials with the low Earth orbit environment and to better understand the potential contamination threats that may be present in the vicinity of spacecraft. Deterioration in the optical performance of candidate space power materials due to the low Earth orbit environment, the contamination environment, or both, must be evaluated in order to propose measures to mitigate such deterioration. The thirty two samples of space power materials studied here include solar array blanket materials such as polyimide Kapton H and SiO(x) coated polyimide Kapton H, front surface aluminized sapphire, solar dynamic concentrator materials such as silver on spin coated polyimide and aluminum on spin coated polyimide, CV 1144 silicone, and the thermal control paint Z-93-P. The physical and optical properties that were evaluated prior to and after the POSA flight include mass, total, diffuse, and specular reflectance, solar absorptance, and infrared emittance. Additional post flight evaluation included scanning electron microscopy to observe surface features caused by the low Earth orbit environment and the contamination environment, and variable angle spectroscopic ellipsometry to identify contaminant type and thickness. This paper summarizes the results of pre- and post-flight measurements, identifies the mechanisms responsible for optical properties deterioration, and suggests improvements for the durability of materials in future missions

A Framework for Successful Research Experiences in the Classroom: Combining the Power of Technology and Mentors

Authentic research opportunities in the classroom are most impactful when they are student-driven and inquiry-based. These experiences are even more powerful when they involve technology and meaningful connections with scientists. In today's classrooms, activities are driven by state required skills, education standards, and state mandated testing. Therefore, programs that incorporate authentic research must address the needs of teachers. NASA's Expedition Earth and Beyond (EEAB) Program has developed a framework that addresses teacher needs and incorporates the use of technology and access to mentors to promote and enhance authentic research in the classroom. EEAB is a student involvement program that facilitates student investigations of Earth or planetary comparisons using NASA data. To promote student-led research, EEAB provides standards-aligned, inquiry-based curricular resources, an implementation structure to facilitate research, educator professional development, and ongoing support. This framework also provides teachers with the option to incorporate the use of technology and connect students with a mentor, both of which can enrich student research experiences. The framework is structured by a modeled 9-step process of science which helps students organize their research. With more schools gaining increased access to technology, EEAB has created an option to help schools take advantage of students' interest and comfort with technology by leveraging the use of available technologies to enhance student research. The use of technology not only allows students to collaborate and share their research, it also provides a mechanism for them to work with a mentor. This framework was tested during the 2010/2011 school year. Team workspaces hosted on Wikispaces for Educators allow students to initiate their research and refine their research question initially without external input. This allows teams to work independently and rely on the skills and interests of team members. Once teams finalize their research question, they are assigned a mentor. The mentor introduces himself/herself, acknowledges the initial work the team has conducted, and asks a focused question to help open the lines of communication. Students continue to communicate with their mentor throughout their research. As research is completed, teams can share their investigation during a virtual presentation. These live presentations allow students to share their research with their mentor, other scientists, other students, parents, and school administrators. After the initial year of testing this authentic research process, EEAB is working to address the many lessons learned. This will allow the program to refine and improve the overall process in an effort to maximize the benefits. Combined, these powerful strategies provide a successful framework to help teachers enhance the skills and motivation of their students, preparing them to become the next generation of scientists, explorers, and STEM-literate citizens of our nation

Spheres of Earth: An Introduction to Making Observations of Earth Using an Earth System's Science Approach. Student Guide

Scientists from the Image Science and Analysis Laboratory (ISAL) at NASA's Johnson Space Center (JSC) work with astronauts onboard the International Space Station (ISS) who take images of Earth. Astronaut photographs, sometimes referred to as Crew Earth Observations, are taken using hand-held digital cameras onboard the ISS. These digital images allow scientists to study our Earth from the unique perspective of space. Astronauts have taken images of Earth since the 1960s. There is a database of over 900,000 astronaut photographs available at http://eol.jsc.nasa.gov . Images are requested by ISAL scientists at JSC and astronauts in space personally frame and acquire them from the Destiny Laboratory or other windows in the ISS. By having astronauts take images, they can specifically frame them according to a given request and need. For example, they can choose to use different lenses to vary the amount of area (field of view) an image will cover. Images can be taken at different times of the day which allows different lighting conditions to bring out or highlight certain features. The viewing angle at which an image is acquired can also be varied to show the same area from different perspectives. Pointing the camera straight down gives you a nadir shot. Pointing the camera at an angle to get a view across an area would be considered an oblique shot. Being able to change these variables makes astronaut photographs a unique and useful data set. Astronaut photographs are taken from the ISS from altitudes of 300 - 400 km (~185 to 250 miles). One of the current cameras being used, the Nikon D3X digital camera, can take images using a 50, 100, 250, 400 or 800mm lens. These different lenses allow for a wider or narrower field of view. The higher the focal length (800mm for example) the narrower the field of view (less area will be covered). Higher focal lengths also show greater detail of the area on the surface being imaged. Scientists from the Image Science and Analysis Laboratory (ISAL) at NASA s Johnson Space Center (JSC) work with astronauts onboard the International Space Station (ISS) who take images of Earth. Astronaut photographs, sometimes referred to as Crew Earth Observations, are taken using hand-held digital cameras onboard the ISS. These digital images allow scientists to study our Earth from the unique perspective of space. Astronauts have taken images of Earth since the 1960s. There is a database of over 900,000 astronaut photographs available at http://eol.jsc.nasa.gov . Images are requested by ISAL scientists at JSC and astronauts in space personally frame and acquire them from the Destiny Laboratory or other windows in the ISS. By having astronauts take images, they can specifically frame them according to a given request and need. For example, they can choose to use different lenses to vary the amount of area (field of view) an image will cover. Images can be taken at different times of the day which allows different lighting conditions to bring out or highlight certain features. The viewing angle at which an image is acquired can also be varied to show the same area from different perspectives. Pointing the camera straight down gives you a nadir shot. Pointing the camera at an angle to get a view across an area would be considered an oblique shot. Being able to change these variables makes astronaut photographs a unique and useful data set. Astronaut photographs are taken from the ISS from altitudes of 300 - 400 km (approx.185 to 250 miles). One of the current cameras being used, the Nikon D3X digital camera, can take images using a 50, 100, 250, 400 or 800mm lens. These different lenses allow for a wider or narrower field of view. The higher the focal length (800mm for example) the narrower the field of view (less area will be covered). Higher focal lengths also show greater detail of the area on the surface being imaged. There are four major systems or spheres of Earth. They are: Atmosphere, Biosphere, Hydrosphe, and Litho/Geosphere

Bioelectrical impedance vector analysis as an indicator of malnutrition in children under five years with and without pneumonia in Mchinji District, Malawi: An exploratory mixed-methods analysis [version 1; peer review: awaiting peer review]

Background: Bioelectrical impedance vector analysis (BIVA) is a non-invasive assessment of body composition and cellular health, which may improve the assessment of nutritional status in sick children. We explored the reliability, clinical utility, and acceptability of BIVA, as an indicator of nutritional status for children under five years with and without pneumonia, in Malawi. Methods: We conducted a parallel convergent mixed-methods exploratory study in Mchinji District Hospital, Malawi, in 2017. We planned to recruit a convenience sample of children aged 0-59 months with clinical pneumonia, and without an acute illness. Children had duplicate anthropometric and BIVA measurements taken. BIVA measurements of phase angle (PA) were taken of the whole body, and trunk and arm segments. Reliability was assessed by comparing the variability in the two measures, and clinical utility by estimating the association between anthropometry and PA using linear regression. Focus group discussions with healthcare workers who had not previously used BIVA instrumentation were conducted to explore acceptability. Results: A total of 52 children (24 with pneumonia and 28 healthy) were analysed. The reliability of sequential PA measurements was lower than anthropometric measurements, but trunk and arm segments performed better. The largest associations with PA were a negative relationship with weight-for-age z-score (WAZ) and PA in children with pneumonia in the trunk segment, and a positive association with WAZ in the full body measurement in healthy children. Healthcare workers in focus group discussions expressed trust in BIVA technology and that it would enable more accurate diagnosis of malnutrition; however, they raised concerns about the sustainability and necessary resources to implement BIVA. Conclusions: While healthcare workers were positive towards BIVA as a novel technology, implementation challenges should be expected. The differential direction of association between anthropometry and PA for children with pneumonia warrants further investigation

Mortality and its risk factors in Malawian children admitted to hospital with clinical pneumonia, 2001–12: a retrospective observational study

Background Few studies have reported long-term data on mortality rates for children admitted to hospital with pneumonia in Africa. We examined trends in case fatality rates for all-cause clinical pneumonia and its risk factors in Malawian children between 2001 and 2012. Methods Individual patient data for children (<5 years) with clinical pneumonia who were admitted to hospitals participating in Malawi’s Child Lung Health Programme between 2001 and 2012 were recorded prospectively on a standardised medical form. We analysed trends in pneumonia mortality and children’s clinical characteristics, and we estimated the association of risk factors with case fatality for children younger than 2 months, 2–11 months of age, and 12–59 months of age using separate multivariable mixed eff ects logistic regression models. Findings Between November, 2012, and May, 2013, we retrospectively collected all available hard copies of yellow forms from 40 of 41 participating hospitals. We examined 113 154 pneumonia cases, 104 932 (92∧7%) of whom had mortality data and 6903 of whom died, and calculated an overall case fatality rate of 6·6% (95% CI 6·4–6·7). The case fatality rate signifi cantly decreased between 2001 (15·2% [13·4–17·1]) and 2012 (4·5% [4·1–4·9]; ptrend<0·0001). Univariable analyses indicated that the decrease in case fatality rate was consistent across most subgroups. In multivariable analyses, the risk factors signifi cantly associated with increased odds of mortality were female sex, young age, very severe pneumonia, clinically suspected Pneumocystis jirovecii infection, moderate or severe underweight, severe acute malnutrition, disease duration of more than 21 days, and referral from a health centre. Increasing year between 2001 and 2012 and increasing age (in months) were associated with reduced odds of mortality. Fast breathing was associated with reduced odds of mortality in children 2–11 months of age. However, case fatality rate in 2012 remained high for children with very severe pneumonia (11·8%), severe undernutrition (15·4%), severe acute malnutrition (34·8%), and symptom duration of more than 21 days (9·0%). Interpretation Pneumonia mortality and its risk factors have steadily improved in the past decade in Malawi; however, mortality remains high in specifi c subgroups. Improvements in hospital care may have reduced case fatality rates though a lack of suffi cient data on quality of care indicators and the potential of socioeconomic and other improvements outside the hospital precludes adequate assessment of why case-fatality rates fell. Results from this study emphasise the importance of eff ective national systems for data collection. Further work combining this with data on trends in the incidence of pneumonia in the community are needed to estimate trends in the overall risk of mortality from pneumonia in children in Malawi

Mortality and its risk factors in Malawian children admitted to hospital with clinical pneumonia, 2001-12: a retrospective observational study.

BACKGROUND: Few studies have reported long-term data on mortality rates for children admitted to hospital with pneumonia in Africa. We examined trends in case fatality rates for all-cause clinical pneumonia and its risk factors in Malawian children between 2001 and 2012. METHODS: Individual patient data for children (<5 years) with clinical pneumonia who were admitted to hospitals participating in Malawi's Child Lung Health Programme between 2001 and 2012 were recorded prospectively on a standardised medical form. We analysed trends in pneumonia mortality and children's clinical characteristics, and we estimated the association of risk factors with case fatality for children younger than 2 months, 2-11 months of age, and 12-59 months of age using separate multivariable mixed effects logistic regression models. FINDINGS: Between November, 2012, and May, 2013, we retrospectively collected all available hard copies of yellow forms from 40 of 41 participating hospitals. We examined 113 154 pneumonia cases, 104 932 (92·7%) of whom had mortality data and 6903 of whom died, and calculated an overall case fatality rate of 6·6% (95% CI 6·4-6·7). The case fatality rate significantly decreased between 2001 (15·2% [13·4-17·1]) and 2012 (4·5% [4·1-4·9]; ptrend<0·0001). Univariable analyses indicated that the decrease in case fatality rate was consistent across most subgroups. In multivariable analyses, the risk factors significantly associated with increased odds of mortality were female sex, young age, very severe pneumonia, clinically suspected Pneumocystis jirovecii infection, moderate or severe underweight, severe acute malnutrition, disease duration of more than 21 days, and referral from a health centre. Increasing year between 2001 and 2012 and increasing age (in months) were associated with reduced odds of mortality. Fast breathing was associated with reduced odds of mortality in children 2-11 months of age. However, case fatality rate in 2012 remained high for children with very severe pneumonia (11·8%), severe undernutrition (15·4%), severe acute malnutrition (34·8%), and symptom duration of more than 21 days (9·0%). INTERPRETATION: Pneumonia mortality and its risk factors have steadily improved in the past decade in Malawi; however, mortality remains high in specific subgroups. Improvements in hospital care may have reduced case fatality rates though a lack of sufficient data on quality of care indicators and the potential of socioeconomic and other improvements outside the hospital precludes adequate assessment of why case-fatality rates fell. Results from this study emphasise the importance of effective national systems for data collection. Further work combining this with data on trends in the incidence of pneumonia in the community are needed to estimate trends in the overall risk of mortality from pneumonia in children in Malawi. FUNDING: Bill & Melinda Gates Foundation

Maternal mental well-being and recent child illnesses–A cross-sectional survey analysis from Jigawa State, Nigeria

Child health indicators in Northern Nigeria remain low. The bidirectional association between child health and maternal well-being is also poorly understood. We aim to describe the association between recent child illness, socio-demographic factors and maternal mental well-being in Jigawa State, Nigeria. We analysed a cross-sectional household survey conducted in Kiyawa local government area, Jigawa State, from January 2020 to March 2020 amongst women aged 16–49 with at least one child under-5 years. We used two-stage random sampling. First, we used systematic random sampling of compounds, with the number of compounds based on the size of the community. The second stage used simple random sampling to select one eligible woman per compound. Mental well-being was assessed using the Short Warwick-Edinburgh Mental Wellbeing Score (SWEMWBS). We used linear regression to estimate associations between recent child illness, care-seeking and socio-demographic factors, and mental well-being. Overall 1,661 eligible women were surveyed, and 8.5% had high mental well-being (metric score of 25.0–35.0) and 29.5% had low mental well-being (metric score of 7.0–17.9). Increasing wealth quintile (adj coeff: 1.53; 95% CI: 0.91–2.15) not being a subsistence farmer (highest adj coeff: 3.23; 95% CI: 2.31–4.15) and having a sick child in the last 2-weeks (adj coeff: 1.25; 95% CI: 0.73–1.77) were significantly associated with higher mental well-being. Higher levels of education and increasing woman’s age were significantly associated with lower mental well-being. Findings contradicted our working hypothesis that a recently sick child would be associated with lower mental well-being. We were surprised that education and late marriage, which are commonly attributed to women’s empowerment and autonomy, were not linked to better well-being here. Future work could focus on locally defined tools to measure well-being reflecting the norms and values of communities, ensuring solutions that are culturally acceptable and desirable to women with low mental well-being are initiated

Risk and accuracy of outpatient-identified hypoxaemia for death among suspected child pneumonia cases in rural Bangladesh: a multifacility prospective cohort study

BACKGROUND: Hypoxaemic pneumonia mortality risk in low-income and middle-income countries is high in children who have been hospitalised, but unknown among outpatient children. We sought to establish the outpatient burden, mortality risk, and prognostic accuracy of death from hypoxaemia in children with suspected pneumonia in Bangladesh. METHODS: We conducted a prospective community-based cohort study encompassing three upazila (subdistrict) health complex catchment areas in Sylhet, Bangladesh. Children aged 3-35 months participating in a community surveillance programme and presenting to one of three upazila health complex Integrated Management of Childhood Illness (IMCI) outpatient clinics with an acute illness and signs of difficult breathing (defined as suspected pneumonia) were enrolled in the study; because lower respiratory tract infection mortality mainly occurs in children younger than 1 year, the primary study population comprised children aged 3-11 months. Study physicians recorded WHO IMCI pneumonia guideline clinical signs and peripheral arterial oxyhaemoglobin saturations (SpO2) in room air. They treated children with pneumonia with antibiotics (oral amoxicillin [40 mg/kg per dose twice per day for 5-7 days, as per local practice]), and recommended oxygen, parenteral antibiotics, and hospitalisation for those with an SpO2 of less than 90%, WHO IMCI danger signs, or severe malnutrition. Community health workers documented the children's vital status and the date of any vital status changes during routine household surveillance (one visit to each household every 2 months). The primary outcome was death at 2 weeks after enrolment in children aged 3-11 months (primary study population) and 12-35 months (secondary study population). Primary analyses included estimating the outpatient prevalence, mortality risk, and prognostic accuracy of hypoxaemia for death in children aged 3-11 months with suspected pneumonia. Risk ratios were produced by fitting a multivariable model that regressed predefined SpO2 ranges (<90%, 90-93%, and 94-100%) on the primary 2-week mortality outcome (binary outcome) using Poisson models with robust variance estimation. We established the prognostic accuracy of WHO IMCI guidelines for death with and without varying SpO2 thresholds. FINDINGS: Participants were recruited between Sept 1, 2015, to Aug 31, 2017. During the study period, a total of 7440 children aged 3-35 months with the first suspected pneumonia episode were enrolled, of whom 3848 (54·3%) with an attempted pulse oximeter measurement and 2-week outcome were included in our primary study population of children aged 3-11-months. Among children aged 3-11 months, an SpO2 of less than 90% occurred in 102 (2·7%) of 3848 children, an SpO2 of 90-93% occurred in 306 (8·0%) children, a failed SpO2 measurement occurred in 67 (1·7%) children, and 24 (0·6%) children with suspected pneumonia died. Compared with an SpO2 of 94-100% (3373 [87·7%] of 3848), the adjusted risk ratio for death was 10·3 (95% CI 3·2-32·3; p<0·001) for an SpO2 of less than 90%, 4·3 (1·5-11·8; p=0·005) for an SpO2 of 90-93%, and 11·4 (3·1-41·4; p<0·001) for a failed measurement. When not considering pulse oximetry, of the children who died, WHO IMCI guidelines identified only 25·0% (95% CI 9·7-46·7; six of 24 children) as eligible for referral to hospital. For identifying deaths, in children with an SpO2 of less than 90% WHO IMCI guidelines had a 41·7% sensitivity (95% CI 22·1-63·4) and 89·7% specificity (88·7-90·7); for children with an SpO2 of less than 90% or measurement failure the guidelines had a 54·2% sensitivity (32·8-74·4) and 88·3% specificity (87·2-89·3); and for children with an SpO2 of less than 94% or measurement failure the guidelines had a 62·5% sensitivity (40·6-81·2) and 81·3% specificity (80·0-82·5). INTERPRETATION: These findings support pulse oximeter use during the outpatient care of young children with suspected pneumonia in Bangladesh as well as the re-evaluation of the WHO IMCI currently recommended threshold of an SpO2 less than 90% for hospital referral. FUNDING: Fogarty International Center of the National Institutes of Health (K01TW009988), The Bill & Melinda Gates Foundation (OPP1084286 and OPP1117483), and GlaxoSmithKline (90063241)