APPLYING STATED-PREFERENCE METHODS TO HEALTH SYSTEMS PROBLEMS IN SUB-SAHARAN AFRICA

Background: Sub-Saharan African country governments face challenges building robust health systems that can deliver essential and routine care consistently and well. Alongside the financial, logistical, and clinical challenges of delivering evidence-based interventions, planners and policymakers are increasingly pressed to be more responsive to stakeholders’ values and preferences in their decisionmaking. For example, mortality from postpartum hemorrhage can be prevented and treated with uterotonic drugs; however, Kenyan stakeholders may disagree how best to strategically address threats to availability, safety, and effectiveness of providing these life-saving medicines. A national community-based health program could deliver essential services where skilled health workers are scarce in Tanzania; however, community health workers, the government, and beneficiaries may value the program’s essential characteristics differently, including worker compensation, supervisory structures, training approaches to encourage retention, and which populations will be served. Systematically assessing preferences and priorities can be a valuable tool for health systems planners and policymakers for incorporating stakeholder voices into health programs. Objectives: Characterize the range of quantitative stated-preference methods applications and approaches to health systems problems in sub-Saharan Africa through a systematic review of the scientific literature (Chapter 3); apply both qualitative and quantitative methods to two health systems problems in sub-Saharan Africa, 1) identify and prioritize strategies to promote uterotonic security in Kenya (Chapter 4); and 2) to identify, assess, and compare factors affecting stakeholders’ preferences for a national community-based health program throughout Tanzania (Chapter 5). Methods: Six databases were queried for peer-reviewed articles using quantitative stated-preference methods to evaluate a health systems-related trade-offs (Chapter 3). Two studies were undertaken. In Kenya, key informants were interviewed to identify potential strategic focal areas to improve uterotonic security. Priorities were assessed among national stakeholders using conjoint analysis. Survey responses were regressed using a linear probability model (Chapter 4). In Tanzania, qualitative research engaging community health workers, governing authorities, and recent clients in four districts in Morogoro Region identified potential program characteristics. Experts were engaged to refine the experiment to align with current policy concerns. Preferences were elicited from community health workers, their governing authorities, and community members throughout Morogoro Region using best-worst scaling techniques. Preference estimates were generated using mixed logit regression (Chapter 5). Results: Seventy-seven articles published between 1996 and 2017 met review criteria. Methods were primarily choice-based. Trade-offs fell into six health systems “building blocks:” service features (n=27), workforce incentives (n=17), product features (n=14), system priorities (n=14), insurance features (n=4), and research priorities (n=1). Discrete-choice experiments were of highest quality (mean score: 3.36/5). Steps for attribute development were generally well described, and frequently included qualitative research (n=50, 65%). In Kenya, 23 informants were interviewed and 11 strategic focal areas were identified: polices and regulations, finance, advocacy and leadership, coordination, health supplies, human resource development, monitoring and evaluation, pharmaceutical quality assurance, service delivery, supply chain strengthening, and provider awareness. Survey respondents (n=66) included maternal health and pharmaceutical commodity experts from government, the public and private sectors. Pharmaceutical quality assurance (p<0.01) and supply chain strengthening (p<0.05) were the most prioritized areas. In Tanzania, interviews (community health workers, n=18; governing authorities, n=34) and discussions (client groups, n=8) yielded 19 potential program characteristics. Six attributes with three levels each were pre-tested and refined: incentives, supervision, eligibility, selection for training, services, and service venue. All survey respondents (community health workers (n=108), governing authorities (n=109), and community members (n=225) favored a community-based health program that provides a set salary (p<0.001), a package of services for the whole family (p<0.001), and disfavored requiring a Form 4 education (p<0.001). Governing authorities and community members preferred community health workers were bonded to service after training (p<0.001), while community health workers as a group were ambivalent. Conclusions: Published stated-preference methods applications on sub-Saharan Africa health systems problems concerned primary health care for women, prevention and treatment of infectious diseases, and workforce development. Fewer studies concerned non-communicable diseases. In both the Kenya and Tanzania studies, a mixed methods approach demonstrated that identifying, assessing, and also comparing priorities using conjoint analysis or preferences using best-worst scaling techniques could be improved through qualitative research, pre-tests with relevant study audiences, and consultation with experts. Survey results from Kenya favor a uterotonic security strategy that emphasizes pharmaceutical quality assurance and supply chain strengthening above all other areas, reflecting ongoing concerns for both the quality and quantity of uterotonic drugs delivered. The national government should engage county governments to identify compatible priorities and consider lessons learned from commodity security approaches for national HIV/AIDS, malaria, childhood immunization, and family planning programs. Survey results from Tanzania suggest similar preferences among the three stakeholder groups that provide for a community-based health program that provides a regular salary to community health workers, does not require community health workers to have a Form 4 education, provides more comprehensive services in public fora and client homes. Our findings provide a consistent picture of stakeholder preferences and clear guidance to health policymakers and planners to implement a national, community-based health program in Tanzania

Connections in Information Literacy Responses: IL in the Undergraduate University Experience

This study was conducted at a four-year state university to compare differences in information literacy knowledge between students at the first-year, sophomore, junior, and senior levels. The survey included questions about reading habits, library usage, and information literacy knowledge, and was shared with 10,967 students with a 15.7% response rate. Analysis of the responses found reduced participation from sophomores, a positive relationship between required course use of the library and actual use of the library, a positive relationship between library exposure and accuracy of responses, and other academic connections to information skills

High-throughput screening in larval zebrafish identifies novel potent sedative-hypnotics

BACKGROUND: Many general anesthetics were discovered empirically, but primary screens to find new sedative-hypnotics in drug libraries have not used animals, limiting the types of drugs discovered. The authors hypothesized that a sedative-hypnotic screening approach using zebrafish larvae responses to sensory stimuli would perform comparably to standard assays, and efficiently identify new active compounds. METHODS: The authors developed a binary outcome photomotor response assay for zebrafish larvae using a computerized system that tracked individual motions of up to 96 animals simultaneously. The assay was validated against tadpole loss of righting reflexes, using sedative-hypnotics of widely varying potencies that affect various molecular targets. A total of 374 representative compounds from a larger library were screened in zebrafish larvae for hypnotic activity at 10 µM. Molecular mechanisms of hits were explored in anesthetic-sensitive ion channels using electrophysiology, or in zebrafish using a specific reversal agent. RESULTS: Zebrafish larvae assays required far less drug, time, and effort than tadpoles. In validation experiments, zebrafish and tadpole screening for hypnotic activity agreed 100% (n = 11; P = 0.002), and potencies were very similar (Pearson correlation, r > 0.999). Two reversible and potent sedative-hypnotics were discovered in the library subset. CMLD003237 (EC50, ~11 µM) weakly modulated γ-aminobutyric acid type A receptors and inhibited neuronal nicotinic receptors. CMLD006025 (EC50, ~13 µM) inhibited both N-methyl-D-aspartate and neuronal nicotinic receptors. CONCLUSIONS: Photomotor response assays in zebrafish larvae are a mechanism-independent platform for high-throughput screening to identify novel sedative-hypnotics. The variety of chemotypes producing hypnosis is likely much larger than currently known.This work was supported by grants from Shanghai Jiaotong University School of Medicine, Shanghai, China, and the Chinese Medical Association, Beijing, China (both to Dr. Yang). The Department of Anesthesia, Critical Care and Pain Medicine of Massachusetts General Hospital, Boston, Massachusetts, supported this work through a Research Scholars Award and an Innovation Grant (both to Dr. Forman). Contributions to this research from the Boston University Center for Molecular Discovery, Boston, Massachusetts (to Drs. Porco, Brown, Schaus, and Xu, and to Mr. Trilles), were supported by a grant from the National Institutes of Health, Bethesda, Maryland (grant No. R24 GM111625). (Shanghai Jiaotong University School of Medicine, Shanghai, China; Chinese Medical Association, Beijing, China; Department of Anesthesia, Critical Care and Pain Medicine of Massachusetts General Hospital, Boston, Massachusetts; R24 GM111625 - National Institutes of Health, Bethesda, Maryland)Accepted manuscript2019-09-0

Is measurement error altered by participation in a physical activity intervention?

WINKLER, E., L. WATERS, E. EAKIN, B. FJELDSOE, N. OWEN, and M. REEVES. Is Measurement Error Altered by Participation in a Physical Activity Intervention? Med. Sci. Sports Exerc., Vol. 45, No. 5, pp. 1004-1011, 2013. Purpose: There is no "gold standard" measure for moderate to vigorous physical activity (MVPA); some error is inherent to self-report and device-based measures. Few studies have examined agreement between self-report and device-based measures in the intervention trial context or whether the difference between measures is influenced by intervention participation. Methods: MVPA was measured at baseline and after 6 months by Active Australia Survey (AAS) and by the GT1M accelerometer (>= 1952 counts per minute) in the intervention (n = 135) and usual care control (n = 141) participants of a randomized trial targeting weight loss by MVPA increases and energy intake reductions in adults with type 2 diabetes. Agreement (for each group at each assessment) was examined using the Bland-Altman approach and regression-based modeling. Because the differences between MVPA measures varied with average values ([AAS + GT1M]/2), they were examined as a percentage of average physical activity. t-tests were used to assess unadjusted group differences and changes over time. ANCOVA models tested intervention effects on measurement error at follow-up, adjusted for baseline. Results: Agreement worsened, and variability in the difference measures became greater, as the average amount of MVPA increased. Measurement error differed significantly between groups at follow-up (P = 0.010) but not at baseline (P = 0.157) and changed significantly within the intervention group (P = 0.001) but not the control group (P = 0.164). There was a statistically significant effect of the intervention on measurement error (P = 0.026). Conclusions: Measurement error of self-report relative to the accelerometer appeared to be affected by intervention. Because measurement error cannot be definitively attributed to self-report or accelerometer, it would be prudent to measure both in future studies

Predictors of Parent Responsiveness to 1-Year-Olds At-Risk for Autism Spectrum Disorder

Parent responsiveness is critical for child development of cognition, social-communication, and self-regulation. Parents tend to respond more frequently when children at-risk for autism spectrum disorder (ASD) demonstrate stronger social-communication; however, it is unclear how responsiveness is associated with sensory characteristics of children at-risk for ASD. To address this issue, we examined the extent to which child social-communication and sensory reactivity patterns (i.e., hyper- and hypo-reactivity) predicted parent responsiveness to 1-year-olds at-risk for ASD in a community sample of 97 parent-infant pairs. A combination of child social-communication and sensory hypo-reactivity consistently predicted how parents played and talked with their 1-year-old at-risk for ASD. Parents tended to talk less and use more play actions when infants communicated less and demonstrated stronger hypo-reactivity

The First Year Inventory: A longitudinal follow-up of 12-month-olds to 3 years of age

The First Year Inventory (FYI) is a parent-report measure designed to identify 12-month old infants at risk for autism spectrum disorder (ASD). The FYI taps behaviors that indicate risk in the developmental domains of sensory-regulatory and social-communication functioning. This longitudinal study is a follow-up of 699 children at 3 years of age from a community sample whose parents completed the FYI when their children were 12 months old. Parents of all 699 children completed the Social Responsiveness Scale – Preschool version (SRS-P) and the Developmental Concerns Questionnaire (DCQ) to determine age 3 developmental outcomes. In addition, children deemed at-risk for ASD based on liberal cut points on the FYI, SRS-P, and/or DCQ were invited for in-person diagnostic evaluations. We found 9 children who had a confirmed diagnosis of ASD from the sample of 699. ROC analyses determined that a two-domain cutoff score yielded optimal classification of children: 31% of those meeting algorithm cut-offs had ASD and 85% had a developmental disability or concern by age three. These results suggest that the FYI is a promising tool for identifying 12-month old infants who are at risk for an eventual diagnosis of ASD

Leveraging Online Learning to Promote Systems Thinking for Sustainable Food Systems Training in Dietetics Education

Educating and training a multisectoral food systems workforce is a critical part of developing sustainable, resilient, and healthy food and water systems. This paper shares perspectives from a working group of educators, learners, and food systems subject matter experts that collaborated over the course of a year to develop, pilot test, and evaluate two interactive webinar series with a multi-site cohort of dietetics interns and graduate students. The three-part webinar series format included a training webinar, a practice activity, and a synthesis webinar. In reflecting on the effectiveness of this format, we provide direct assessments of student learning from subject matter experts alongside indirect assessments from pre- and post-surveys fielded with learners. Learners who participated in an interactive webinar series demonstrated skills in several dimensions of systems thinking and gained confidence in food systems learning outcomes. Learners also shared valuable feedback on the opportunities and challenges of using online platforms for this experience. As online learning opportunities become more common, it will become increasingly important for educators to prioritize strategies that effectively equip students with the higher-order thinking skills, such as systems thinking, needed to address the complexities of sustainable food systems. The interactive webinar series format described here provides an opportunity to leverage didactic webinars in combination with interactive experiences that enable learners to deepen their knowledge through practice with peers and subject matter experts. Though this format was piloted within dietetics education programs, many of the lessons learned are transferable to other food systems educational contexts

Uncovering hidden genetic variation in photosynthesis of field‐grown maize under ozone pollution

Ozone is the most damaging air pollutant to crops, currently reducing Midwest US maize production by up to 10%, yet there has been very little effort to adapt germ‐ plasm for ozone tolerance. Ozone enters plants through stomata, reacts to form reactive oxygen species in the apoplast and ultimately decreases photosynthetic C gain. In this study, 10 diverse inbred parents were crossed in a half‐diallel design to create 45 F1 hybrids, which were tested for ozone response in the field using free air concentration enrichment (FACE). Ozone stress increased the heritability of pho‐ tosynthetic traits and altered genetic correlations among traits. Hybrids from par‐ ents Hp301 and NC338 showed greater sensitivity to ozone stress, and disrupted relationships among photosynthetic traits. The physiological responses underlying sensitivity to ozone differed in hybrids from the two parents, suggesting multiple mechanisms of response to oxidative stress. FACE technology was essential to this evaluation because genetic variation in photosynthesis under elevated ozone was not predictable based on performance at ambient ozone. These findings suggest that selection under elevated ozone is needed to identify deleterious alleles in the world's largest commodity crop