The challenge of complexity in evaluating health policies and programs: the case of women's participatory groups to improve antenatal outcomes.

BACKGROUND: During the last years, randomized designs have been promoted as the cornerstone of evidence-based policymaking. Also in the field of community participation, Random Control Trials (RCTs) have been the dominant design, used for instance to examine the contribution of community participation to health improvement. We aim at clarifying why RCTs and related (quasi-) experimental designs may not be the most appropriate approach to evaluate such complex programmes. RESULTS: We argue that the current methodological debate could be more fruitful if it would start from the position that the choice of designs should fit the nature of the program and research questions rather than be driven by methodological preferences. We present how realist evaluation, a theory-driven approach to research and evaluation, is a relevant methodology that could be used to assess whether and how community participation works. Using the realist evaluation approach to examine the relationship between participation and action of women groups and antenatal outcomes would enable evaluators to examine in detail the underlying mechanisms which influence actual practices and outcomes, as well as the context conditions required to make it work. CONCLUSIONS: Realist research in fact allows opening the black boxes of "community" and "participation" in order to examine the role they play in ensuring cost-effective, sustainable interventions. This approach yields important information for policy makers and programme managers considering how such programs could be implemented in their own setting

Médiation informationnelle au travers d’un dispositif socionumérique : hybridation d’un cours pour étudiants de 4e année de licence

International audienc

Un modèle de cinétique d'évolution de populations de bulles dans un fluide à seuil

International audienceThe context of this study is to predict the swelling of bitumen drums in which radioactive salts are mixed (60 wt% of bitumen and 40 wt% of salts). Radioactivity generates uniform volume production of hydrogen by radiolysis of bitumen chains. The creation of gas occurs on very large time scales (more than a hundred years), hence the need to provide model in order to predict the swelling. It has been shown that bitumen is a yield stress fluid. Therefore this work proposes to study the influence of a continuous gas generation and a yield stress on the kinetic evolution of a bubble population. Usually, when a gas is dissolved beyond its solubility limit without yield stress or gas creation, one observes a nucleation-growth-ripening scenario (growth of large bubbles to the detriment of small ones). It selects a distribution of large bubbles over long times, independently of the initial distribution of nuclei. Our work shows that in some cases the gas creation competes with the ripening kinetics and the yield stress can make the bubble population bimodal during its evolution.Le contexte de cette étude est de décrire les processus physico-chimiques élémentaires de base conduisant au gonflement d’enrobés de bitume (suspensions de sels dans une matrice bitume) dans lequel sont conditionnés des sels de coprécipitation de radionucléides. La radioactivité génère une production volumique uniforme de dihydrogène par radiolyse des chaînes de bitume. Ce taux de création de gaz perdure sur des échelles de temps très grandes (plus de cent ans), bien que décroissant au cours du temps. L’étude scientifique vise à conforter les modèles actuels de prédiction du gonflement sous radiolyse des enrobés bitume. Il a été montré que les enrobés de bitume sont des fluides à seuil. Ces travaux proposent donc d'aborder l'influence d’une génération continue de gaz (appelée terme source dans la suite de cet article) et d’un seuil d’écoulement sur la cinétique d'évolution d'une population de bulles. Classiquement, pour un gaz dissous au delà de sa limite de solubilité et en l’absence de seuil et de terme source, on observe un scénario de germination-croissance-mûrissement (croissance des grosses bulles au détriment des petites) qui sélectionne aux temps longs une distribution de grosses bulles, indépendante de la distribution initiale de germes. Nos travaux montrent qu’il existe des régimes où le terme source entre en compétition avec la cinétique de mûrissement et où le seuil d’écoulement peut étaler ou rendre bidisperse la distribution de taille de bulles au cours de son évolution

Prediction and overview of the RpoN-regulon in closely related species of the Rhizobiales

BACKGROUND: In the rhizobia, a group of symbiotic Gram-negative soil bacteria, RpoN (σ(54), σ(N), NtrA) is best known as the sigma factor enabling transcription of the nitrogen fixation genes. Recent reports, however, demonstrate the involvement of RpoN in other symbiotic functions, although no large-scale effort has yet been undertaken to unravel the RpoN-regulon in rhizobia. We screened two complete rhizobial genomes (Mesorhizobium loti, Sinorhizobium meliloti) and four symbiotic regions (Rhizobium etli, Rhizobium sp. NGR234, Bradyrhizobium japonicum, M. loti) for the presence of the highly conserved RpoN-binding sites. A comparison was also made with two closely related non-symbiotic members of the Rhizobiales (Agrobacterium tumefaciens, Brucella melitensis). RESULTS: A highly specific weight-matrix-based screening method was applied to predict members of the RpoN-regulon, which were stored in a highly annotated and manually curated dataset. Possible enhancer-binding proteins (EBPs) controlling the expression of RpoN-dependent genes were predicted with a profile hidden Markov model. CONCLUSIONS: The methodology used to predict RpoN-binding sites proved highly effective as nearly all known RpoN-controlled genes were identified. In addition, many new RpoN-dependent functions were found. The dependency of several of these diverse functions on RpoN seems species-specific. Around 30% of the identified genes are hypothetical. Rhizobia appear to have recruited RpoN for symbiotic processes, whereas the role of RpoN in A. tumefaciens and B. melitensis remains largely to be elucidated. All species screened possess at least one uncharacterized EBP as well as the usual ones. Lastly, RpoN could significantly broaden its working range by direct interfering with the binding of regulatory proteins to the promoter DNA

'They are after quantity, not quality' : health providers’ perceptions of fee exemption policies in Morocco

Background: A free obstetric care policy (FOCP) has been implemented in Morocco in 2008 in order to further decrease maternal mortality. Methods: Through in-depth interviews we explored the perceptions of health professionals in public Moroccan hospitals with regard to fee exemption policies. We tried to understand what drives health professionals to ignore, modify or apply a health policy as formulated. Results: Respondents express significant influences of such policies on their work environment (higher workload and scarcity of resources) and on the patient/provider relationship, both of which may cause a negative effect on health workers' motivation. A mix of motivational determinants incites health workers in their turn to influence policy implementation. Conclusion: Understanding the motivational determinants of health workers may optimize policy implementation at the point of service delivery

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