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Background: The partograph has been endorsed by World Health Organization (WHO) since 1994 which presents an algorithm for assessing maternal and foetal conditions and labor progression. Monitoring labour with a partograph can reduce adverse pregnancy outcomes such as prolonged labor, emergency C-sections, birth asphyxia and stillbirths. However, partograph use is still very low, particularly in low and middle income countries (LMICs). In Bangladesh the reported partograph user rate varies from 1.4% to 33.0%. Recently, an electronic version of the partograph, with the provision of online data entry and user aid for emergency clinical support, has been tested successfully in different settings. With this proven evidence, we conducted and operations research to test the feasibility and effectiveness of implementing an e-partograph, for the first time, in 2 public hospitals in Bangladesh Methods: We followed a prospective crossover design. Two secondary level referral hospitals, Jessore and Kushtia District Hospital (DH) were the study sites. All pregnant women who delivered in the study hospitals were the study participants. All nurse-midwives working in the labor ward of study hospitals were trained on appropriate use of both types of partograph along with standard labour management guidelines. Collected quantitative data was analyzed using SPSS 23 statistical software. Discrete variables were expressed as percentages and presented as frequency distribution and cross tabulations. Chi square tests were employed to test the association between exposure and outcome variables. Potential confounding factors were adjusted using multivariate binary logistic regression methods. Ethical approval was obtained from the institutional review board of the International Centre for Diarrheal Disease Research, Bangladesh (icddr,b). Findings: In total 2918 deliveries were conducted at Jessore DH and 2312 at Kushtia DH during one-year study period. Of them, 1012 (506 in each facility) deliveries were monitored using partograph (paper or electronic). The trends of facility based C-section rates was downwards in both the hospitals; 43% to 37% in Jessore and from 36% to 25% in Kushtia Hospital. There was a significant reduction of prolonged labour with e-partograph use. In Kushtia DH, the prolonged labour rate was 42% during phase 1 with the paper version which came down to 29% during phase-2 with the e-partograph use. The similar result was observed in Jessore DH where the prolonged labour rate reduced to 7% with paper partograph from the reported 30% prolonged labour with e-partograph. The e-partograph user rate was higher than the paper partograph during both phases (phase 1: 3.31, CI: 2.04–5.38, p < .001 and in phase 2: 15.20 CI: 6.36–36.33, p < .001) after adjusting for maternal age, parity, gestational age, religion, mother’s education, husband’s education, and fetal sex Conclusion: The partograph user rate has significantly improved with the e- partograph and was associated with an overall reduction in cesarean births. Use of the e-partograph was also associated with reduced rates of prolonged labour. This study has added to the growing body of evidence on the positive impact of e-partograph use. We recommend implementing e-partograph intervention at scale in both public and private hospitals in Bangladesh. Trial registration: ClinicalTrials.gov . [ABSTRACT FROM AUTHOR]

The UK is one of the largest funders of health research in the world, but little is known about how health funding is spent. Our study explores whether major UK public and charitable health research funders support the research of UK-based scientists producing the most highly-cited research. To address this question, we searched for UK-based authors of peer-reviewed papers that were published between January 2006 and February 2018 and received over 1000 citations in Scopus. We explored whether these authors have held a grant from the National Institute for Health Research (NIHR), the Medical Research Council (MRC) and the Wellcome Trust and compared the results with UK-based researchers who serve currently on the boards of these bodies. From the 1,370 papers relevant to medical, biomedical, life and health sciences with more than 1000 citations in the period examined, we identified 223 individuals from a UK institution at the time of publication who were either first/last or single authors. Of those, 164 are still in UK academic institutions, while 59 are not currently in UK academia (have left the country, are retired, or work in other sectors). Of the 164 individuals, only 59 (36%; 95% CI: 29–43%) currently hold an active grant from one of the three funders. Only 79 (48%; 95% CI: 41–56%) have held an active grant from any of the three funders between 2006–2017. Conversely, 457 of the 664 board members of MRC, Wellcome Trust, and NIHR (69%; 95% CI: 65–72%) have held an active grant in the same period by any of these funders. Only 7 out of 655 board members (1.1%) were first, last or single authors of an extremely highly-cited paper. There are many reasons why the majority of the most influential UK authors do not hold a grant from the country’s major public and charitable funding bodies. Nevertheless, the results are worrisome and subscribe to similar patterns shown in the US. We discuss possible implications and suggest ways forward. [ABSTRACT FROM AUTHOR]

Introduction: Data collection using paper-based questionnaires can be time consuming and return errors affect data accuracy, completeness, and information quality in health surveys. We compared smartphone and paper-based data collection systems in the Burden of Obstructive Lung Disease (BOLD) study in rural Sudan. Methods: This exploratory pilot study was designed to run in parallel with the cross-sectional household survey. The Open Data Kit was used to programme questionnaires in Arabic into smartphones. We included 100 study participants (83% women; median age = 41.5 ± 16.4 years) from the BOLD study from 3 rural villages in East-Gezira and Kamleen localities of Gezira state, Sudan. Questionnaire data were collected using smartphone and paper-based technologies simultaneously. We used Kappa statistics and inter-rater class coefficient to test agreement between the two methods. Results: Symptoms reported included cough (24%), phlegm (15%), wheezing (17%), and shortness of breath (18%). One in five were or had been cigarette smokers. The two data collection methods varied between perfect to slight agreement across the 204 variables evaluated (Kappa varied between 1.00 and 0.02 and inter-rater coefficient between 1.00 and -0.12). Errors were most commonly seen with paper questionnaires (83% of errors seen) vs smartphones (17% of errors seen) administered questionnaires with questions with complex skip-patterns being a major source of errors in paper questionnaires. Automated checks and validations in smartphone-administered questionnaires avoided skip-pattern related errors. Incomplete and inconsistent records were more likely seen on paper questionnaires. Conclusion: Compared to paper-based data collection, smartphone technology worked well for data collection in the study, which was conducted in a challenging rural environment in Sudan. This approach provided timely, quality data with fewer errors and inconsistencies compared to paper-based data collection. We recommend this method for future BOLD studies and other population-based studies in similar settings. [ABSTRACT FROM AUTHOR]

The article offers information on catalyzing Neglected Tropical Diseases (NTD) gender and equity research. Topics discussed include significance of the NTD program predicated opportunity to treat disease, prevent morbidity and disability, and interrupt infection transmission among large populations; addresses the issue of gender equity, organizational, policy, and practice activities; and sex and gender roles can profound effect on healthcare access and health outcomes.

The article presents several rules for restructuring papers to avoid losing readers. Authors are instructed to focus their papers on a central contribution and to concentrate on the context-content-conclusion (C-C-C) scheme. They are also advised to optimize a paper's logical flow by avoiding zig-zag and using parallelism and to include complete story in the abstract.

Background: Little is known about how adverse events are summarised and reported in trials, as detailed information is usually considered confidential. We have acquired clinical study reports (CSRs) from the European Medicines Agency through the Freedom of Information Act. The CSRs describe the results of studies conducted as part of the application for marketing authorisation for the slimming pill orlistat. The purpose of this study was to study how adverse events were summarised and reported in study protocols, CSRs, and published papers of orlistat trials.Methods and Findings: We received the CSRs from seven randomised placebo controlled orlistat trials (4,225 participants) submitted by Roche. The CSRs consisted of 8,716 pages and included protocols. Two researchers independently extracted data on adverse events from protocols and CSRs. Corresponding published papers were identified on PubMed and adverse event data were extracted from this source as well. All three sources were compared. Individual adverse events from one trial were summed and compared to the totals in the summary report. None of the protocols or CSRs contained instructions for investigators on how to question participants about adverse events. In CSRs, gastrointestinal adverse events were only coded if the participant reported that they were "bothersome," a condition that was not specified in the protocol for two of the trials. Serious adverse events were assessed for relationship to the drug by the sponsor, and all adverse events were coded by the sponsor using a glossary that could be updated by the sponsor. The criteria for withdrawal due to adverse events were in one case related to efficacy (high fasting glucose led to withdrawal), which meant that one trial had more withdrawals due to adverse events in the placebo group. Finally, only between 3% and 33% of the total number of investigator-reported adverse events from the trials were reported in the publications because of post hoc filters, though six of seven papers stated that "all adverse events were recorded." For one trial, we identified an additional 1,318 adverse events that were not listed or mentioned in the CSR itself but could be identified through manually counting individual adverse events reported in an appendix. We discovered that the majority of patients had multiple episodes of the same adverse event that were only counted once, though this was not described in the CSRs. We also discovered that participants treated with orlistat experienced twice as many days with adverse events as participants treated with placebo (22.7 d versus 14.9 d, p-value < 0.0001, Student's t test). Furthermore, compared with the placebo group, adverse events in the orlistat group were more severe. None of this was stated in the CSR or in the published paper. Our analysis was restricted to one drug tested in the mid-1990s; our results might therefore not be applicable for newer drugs.Conclusions: In the orlistat trials, we identified important disparities in the reporting of adverse events between protocols, clinical study reports, and published papers. Reports of these trials seemed to have systematically understated adverse events. Based on these findings, systematic reviews of drugs might be improved by including protocols and CSRs in addition to published articles. [ABSTRACT FROM AUTHOR]

Background: Type 2 diabetes mellitus (T2DM) is an established risk factor for cardiovascular and nephropathic events. In the Netherlands, prevalence of T2DM is expected to be as high as 8% by 2025. This will result in significant clinical and economic impact, highlighting the need for well-informed reimbursement decisions for new treatments. However, availability and consistent use of costing methodologies is limited. Objective: We aimed to systematically review recent costing data for T2DM-related cardiovascular and nephropathic events in the Netherlands. Methods: A systematic literature review in PubMed and Embase was conducted to identify available Dutch cost data for T2DM-related events, published in the last decade. Information extracted included costs, source, study population, and costing perspective. Finally, papers were evaluated using the Consolidated Health Economic Evaluation Reporting Standards (CHEERS). Results: Out of initially 570 papers, 36 agreed with the inclusion criteria. From these studies, 150 cost estimates for T2DM-related clinical events were identified. In total, 29 cost estimates were reported for myocardial infarction (range: €196-€27,038), 61 for stroke (€495-€54,678), fifteen for heart failure (€325-€16,561), 24 for renal failure (€2,438-€91,503), and seventeen for revascularisation (€3,000-€37,071). Only four estimates for transient ischaemic attack were available, ranging from €587 to €2,470. Adherence to CHEERS was generally high. Conclusions: The most expensive clinical events were related to renal failure, while TIA was the least expensive event. Generally, there was substantial variation in reported cost estimates for T2DM-related events. Costing of clinical events should be improved and preferably standardised, as accurate and consistent results in economic models are desired. [ABSTRACT FROM AUTHOR]

Physical inactivity has been identified as a leading risk factor for premature mortality globally, and adolescents, in particular, have low physical activity levels. Schools have been identified as a setting to tackle physical inactivity. Economic evidence of school-based physical activity programmes is limited, and the costs of these programmes are not always collected in full. This paper describes a micro-costing and cost-consequence analysis of the ‘Girls Active’ secondary school-based programme as part of a cluster randomised controlled trial (RCT). Micro-costing and cost-consequence analyses were conducted using bespoke cost diaries and questionnaires to collect programme delivery information. Outcomes for the cost-consequence analysis included health-related quality of life measured by the Child Health Utility-9D (CHU-9D), primary care General Practitioner (GP) and school-based (school nurse and school counsellor) service use as part of a cluster RCT of the ‘Girls Active’ programme. Overall, 1,752 secondary pupils were recruited and a complete case sample of 997 participants (Intervention n = 570, Control n = 427) was used for the cost-consequence analysis. The micro-costing analysis demonstrated that, depending upon how the programme was delivered, ‘Girls Active’ costs ranged from £1,054 (£2 per pupil, per school year) to £3,489 (£7 per pupil, per school year). The least costly option was to absorb ‘Girls Active’ strictly within curriculum hours. The analysis demonstrated no effect for the programme for the three main outcomes of interest (health-related quality of life, physical activity and service use).Micro-costing analyses demonstrated the costs of delivering the ‘Girls Active’ programme, addressing a gap in the United Kingdom (UK) literature regarding economic evidence from school-based physical activity programmes. This paper provides recommendations for those gathering cost and service use data in school settings to supplement validated and objective measures, furthering economic research in this field. Trial registration: -ISRCTN, . [ABSTRACT FROM AUTHOR]

Objectives: Little is known about the gender and age differences associated with the effects of economic fluctuations on hospitalization for cardiovascular diseases. This paper investigates the impact of economic fluctuations on hospitalization for ischemic heart disease (IHD), stroke, and hypertension by age and gender between January 1996 and December 2012 in Taiwan. Methods: We adopted a multiple-input time series analysis to examine the strength of the immediate and latent effects of the 17-year quarterly unemployment rates (UR), air pollution exposure (APE), gross domestic product (GDP), per capita consumption expenditure in cigarette and alcohol (ECA), and per capita healthcare expenditure (HE) on the adjusted quarterly incidence rate of hospitalization. The data used in this paper were retrieved from the National Health Insurance Research Database and the website of the Directorate-General of Budget, Accounting and Statistics (DGBAS), Executive Yuan. Results: Our findings indicate that higher UR increased IHD hospitalization in young men and women and middle-aged women but reduced stroke hospitalization in young men. Higher APE increased IHD hospitalization in young men but reduced it for young women, increased stroke hospitalization in old men and middle-aged women but reduced it for young men, and increased hypertension hospitalization in middle-aged men and young women. Higher ECA reduced IHD hospitalization in middle-aged men, increased stoke hospitalization in middle-aged and old men and middle-aged women. Higher HE reduced IHD hospitalization in old men, young and old women, reduced stroke hospitalization in old women, and reduced hypertension hospitalization in young and middle-aged women. Conclusions: Overall, we found that the economic fluctuations caused increased harmful effects in certain population subgroups but also brought some soothing effects to some groups. [ABSTRACT FROM AUTHOR]

Rationale, aims and objective: Substituting outpatient hospital care with primary care is seen as a solution to decrease unnecessary referrals to outpatient hospital care and decrease rising healthcare costs. This systematic review aimed to evaluate the effects on quality of care, health and costs outcomes of substituting outpatient hospital care with primary care-based interventions, which are performed by medical specialists in face-to-face consultations in a primary care setting. Method: The systematic review was performed using the PICO framework. Original papers in which the premise of the intervention was to substitute outpatient hospital care with primary care through the involvement of a medical specialist in a primary care setting were eligible. Results: A total of 14 papers were included. A substitution intervention in general practitioner (GP) practices was described in 11 papers, three described a joint consultation intervention in which GPs see patients together with a medical specialist. This study showed that substitution initiatives result mostly in favourable outcomes compared to outpatient hospital care. The initiatives resulted mostly in shorter waiting lists, shorter clinic waiting times and higher patient satisfaction. Costs for treating one extra patient seemed to be higher in the intervention settings. This was mainly caused by inefficient planning of consultation hours and lower patient numbers. Conclusions: Despite the fact that internationally a lot has been written about the importance of performing substitution interventions in which preventing unnecessary referrals to outpatient hospital care was the aim, only 14 papers were included. Future systematic reviews should focus on the effects on the Triple Aim of substitution initiatives in which other healthcare professions than medical specialists are involved along with new technologies, such as e-consults. Additionally, to gain more insight into the effects of substitution initiatives operating in a dynamic healthcare context, it is important to keep evaluating the interventions in a longitudinal study design. [ABSTRACT FROM AUTHOR]

In epidemiology, gerontology, human development and the social sciences, age-period-cohort (APC) models are used to study the variability in trajectories of change over time. A well-known issue exists in simultaneously identifying age, period and birth cohort effects, namely that the three characteristics comprise a perfectly collinear system. That is, since age = period−cohort, only two of these effects are estimable at a time. In this paper, we introduce an alternative framework for considering effects relating to age, period and birth cohort. In particular, instead of directly modeling age in the presence of period and cohort effects, we propose a risk modeling approach to characterize age-related risk (i.e., a hybrid of multiple biological and sociological influences to evaluate phenomena associated with growing older). The properties of this approach, termed risk-period-cohort (RPC), are described in this paper and studied by simulations. We show that, except for pathological circumstances where risk is uniquely determined by age, using such risk indices obviates the problem of collinearity. We also show that the size of the chronological age effect in the risk prediction model associates with the correlation between a risk index and chronological age and that the RPC approach can satisfactorily recover cohort and period effects in most cases. We illustrate the advantages of RPC compared to traditional APC analysis on 27496 individuals from NHANES survey data (2005–2016) to study the longitudinal variability in depression screening over time. Our RPC method has broad implications for examining processes of change over time in longitudinal studies. [ABSTRACT FROM AUTHOR]

Objectives: The main purpose of this paper was to model the process by which patients enter the ED, are seen by physicians, and discharged from the Emergency Department at Nationwide Children’s Hospital, as well as identify modifiable factors that are associated with ED lengths of stay through use of multistate modeling. Methods: In this study, 75,591 patients admitted to the ED from March 1st, 2016 to February 28th, 2017 were analyzed using a multistate model of the ED process. Cox proportional hazards models with transition-specific covariates were used to model each transition in the multistate model and the Aalen-Johansen estimator was used to obtain transition probabilities and state occupation probabilities in the ED process. Results: Acuity level, season, time of day and number of ED physicians had significant and varying associations with the six transitions in the multistate model. Race and ethnicity were significantly associated with transition to left without being seen, but not with the other transitions. Conversely, age and gender were significantly associated with registration to room and subsequent transitions in the model, though the magnitude of association was not strong. Conclusions: The multistate model presented in this paper decomposes the overall ED length of stay into constituent transitions for modeling covariate-specific effects on each transition. This allows physicians to understand the ED process and identify which potentially modifiable covariates would have the greatest impact on reducing the waiting times in each state in the model. [ABSTRACT FROM AUTHOR]

Background: While school-aged children in low- and middle-income countries remain highly exposed to acute infections, programs targeting this age group remain limited in scale and scope. In this paper, we evaluate the impact of a new and comprehensive primary school-based health intervention program on student-reported morbidity and anthropometric outcomes in Lusaka, Zambia. Methods: A prospective matched control study identified 12 classes in 7 schools for the intervention and 12 classes in 7 matched schools as controls. Teachers in intervention schools were trained to deliver health lessons and to refer sick students to care. In addition, vitamin A and deworming medication were biannually administered to intervention students. The primary study outcome was student-reported morbidity. Secondary outcomes were weight, height, health knowledge, and absenteeism. Multivariable linear and logistic regression models were used to estimate program impact. Results: 380 students ages 4–16 were enrolled in the study in 2015, and 97% were followed up at endline in 2016. The intervention decreased the adjusted odds of self-reported acute illnesses by 38% (95% CI: 0.48, 0.77) and the adjusted odds of stunting by 52% (95% CI: 0.26, 0.87). It also increased health knowledge by 0.53 standard deviations (95% CI: 0.24, 0.81). No impact was found on weight (adjusted mean difference β = 0.17, 95% CI: - 1.11, 1.44) and student absenteeism (adjusted odds ratio (aOR) = 0.89, 95% CI: 0.60, 1.33). Conclusion: The results presented in this paper suggest that comprehensive school-based health programs may offer a highly effective way to improve students’ health knowledge as well as their health status. Given their low cost, a more general adoption and implementation of such programs seems recommendable. Trial registration: ClinicalTrials.gov Identifier: . [ABSTRACT FROM AUTHOR]

This paper examines the levels of health system efficiency and their possible determinants across Latin American and Caribbean (LAC) countries using national-level data for those countries, as well as for other emerging and developed countries. The data are analyzed using data envelopment analyses and econometric advances that yield reliable estimations of the relationship between system efficiency and its potential determinants. We find that there is substantial room for efficiency improvements in the health system of most LAC countries. For example, LAC countries could improve life expectancy at birth by about five years on average at current public spending levels if they followed best practices. Furthermore, the paper assesses what factors amenable to policy act as the main possible levers for some countries to be able to translate a given level of health financing into better performance on access to care and health outcomes. Our econometric analyses suggest that efforts to increase health system efficiency could be focused in a few key policy areas associated with broader access to health services and better outcomes. These areas include general governance aspects, in addition to improvements in specific dimensions of the quality of health system institutions, notably stronger reliance on results-based management in the production of healthcare goods and services. [ABSTRACT FROM AUTHOR]

Background: With an estimated 27 million annual incidents of maternal morbidity globally, how they are manifested or experienced is diverse and shaped by societal, cultural and personal influences. Using qualitative research to examine a woman's perception of her pregnancy, its complications, and potential long-term impact on her life can inform public health approaches and complement and inform biomedical classifications of maternal morbidities, historically considered a neglected dimension of safe motherhood. As part of the WHO’s Maternal Morbidity Working Group’s efforts to define and measure maternal morbidity, we carried out a thematic analysis of the qualitative literature published between 1998 and 2017 on how women experience maternal morbidity in low and lower-middle income countries. Results and conclusions: Analysis of the 71 papers included in this study shows that women’s status, their marital relationships, cultural attitudes towards fertility and social responses to infertility and pregnancy trauma are fundamental to determining how they will experience morbidity in the pregnancy and postpartum periods. We explore the physical, economic, psychological and social repercussions pregnancy can produce for women, and how resource disadvantage (systemic, financial and contextual) can exacerbate these problems. In addition to an analysis of ten themes that emerged across the different contexts, this paper presents which morbidities have received attention in different regions and the trends in researching morbidities over time. We observed an increase in qualitative research on this topic, generally undertaken through interviews and focus groups. Our analysis calls for the pursuit of high quality qualitative research that includes repeat interviews, participant observation and triangulation of sources to inform and fuel critical advocacy and programmatic work on maternal morbidities that addresses their prevention and management, as well as the underlying systemic problems for women’s status in society. [ABSTRACT FROM AUTHOR]

This paper reports the impact of a major life event–death–on the physical, psychological and social well-being of the deceased’s close friends. We utilised data from a large longitudinal survey covering a period of 14 years (2002–2015) consisting a cohort of 26,515 individuals in Australia, of whom 9,586 had experienced the death of at least one close friend. This longitudinal cohort dataset comprises responses to the SF-36 (health related quality of life measure) and allowed for analysis of the short and longer-term impacts of bereavement. In order to manage the heterogeneity of the socio-demographics of respondents who did/not experience a death event, we use a new and robust approach known as the Entropy Balancing method to construct a set of weights applied to the bereaved group and the control group (the group that did not experience death). This approach enables us to match the two groups so that the distribution of socio-demographic variables between the two groups are balanced. These variables included gender, age, marital status, ethnicity, personality traits, religion, relative socio-economic disadvantage, economic resources, and education and occupation and where they resided. The data show, for the first time, a range of negative and enduring consequences experienced by people following the death of a close friend. Significant adverse physical and psychological well-being, poorer mental health and social functioning occur up to four years following bereavement. Bereaved females experienced a sharper fall in vitality, suffered greater deterioration in mental health, impaired emotional and social functioning than the male counterparts up to four years after the death. The data show that the level of social connectedness plays an important role in bereavement outcomes. Specifically, we found that less socially active respondents experienced a longer deterioration in physical and psychological health. Finally, we found evidence that the death of a close friend lowered the respondent’s satisfaction with their health. Since death of friends is a universal phenomenon, we conclude the paper by reflecting on the need to recognise the death of a close friend as a substantial experience, and to offer support and services to address this disenfranchised grief. Recognising bereaved friends as a group experiencing adverse outcomes can be used internationally to prompt health and psychological services to assist this specific group, noting that there may be substantial longevity to the negative sequelae of the death of a friend. Facilitating bereaved people’s support networks may be a fruitful approach to minimising these negative outcomes. [ABSTRACT FROM AUTHOR]

In this paper, we aim to establish a mathematical model to design a maximizing social welfare intervention mechanism of healthcare service goods in China. The intervention mechanism is helpful to facilitate the adoption of the healthcare service goods. We consider a research problem that regulates the supply chain system for healthcare service goods by an intervention mechanism, and two intervention strategies composed of demand-growth strategy and subsidy strategy are used to the combination of intervention mechanism. Then this paper presents a new method based on fuzzy set and bilevel programming to design the intervention mechanism. To demonstrate the effectiveness of the proposed model, we conduct a case study for Wudang personalized health package and verify our model by the specific result analysis, the result indicates that our joint intervention mechanism is helpful to achieve the target and increase social welfare. [ABSTRACT FROM AUTHOR]

Introduction: Community nursing and midwifery is changing in response to a shift in care from hospital to home, brought about by increasing costs to care because of an aging population and increasing chronicity. Until now, community nursing positions and scope of practice has been dependent on service focus and location, which has led to the role being unclearly defined. Lack of appeal for a career in community practice and a looming workforce shortage necessitates a review into how community nursing and midwifery transition to practice is supported. Methods: This review sought to identify, assess and summarize available evidence relating to transitioning into community nursing and midwifery practice as a speciality. A systematic review was conducted using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses approach. A narrative synthesis was then undertaken on papers that examined community nursing and midwifery pathway perspectives which define, and enable or inhibit a contemporary pathway. Thematic analysis used a theoretical framework developed for early career and rapid transition to nursing specialty practice. Results: There is a paucity of research that identifies community nursing and midwifery as a discreet scope of practice. Twelve papers were eventually included in the review. Verbatim findings were extracted from the papers and clustered into categories based on the chosen theoretical framework. Major themes were ‘the self’ (professional and personal); ‘transition processes’; and, a ‘sense of belonging’. Sub themes included narrative identifying inhibitors and enablers in each theme. Discussion: No definition of community practice or pathway was identified in nursing, although midwifery was clearly defined. Community nursing practice was described as generalist in nature although specialist knowledge is required. Being part of the community in the professional sense and personal sense was considered important. The importance of transition was identified where pre-entry exposure to community practice was seen as important. Stages in transition to practice were recognised as pre-entry; incomer; insider; and, a sense of belonging. The process of transition should be planned and individualised acknowledging past experience whilst acknowledging the specialist nature of community-based practice. [ABSTRACT FROM AUTHOR]

Background: Scabies is a common dermatological condition, affecting more than 130 million people at any time. To evaluate and/or predict the effectiveness and cost-effectiveness of scabies interventions, disease transmission modelling can be used. Objective: To review published scabies models and data to inform the design of a comprehensive scabies transmission modelling framework to evaluate the cost-effectiveness of scabies interventions. Methods: Systematic literature search in PubMed, Medline, Embase, CINAHL, and the Cochrane Library identified scabies studies published since the year 2000. Selected papers included modelling studies and studies on the life cycle of scabies mites, patient quality of life and resource use. Reference lists of reviews were used to identify any papers missed through the search strategy. Strengths and limitations of identified scabies models were evaluated and used to design a modelling framework. Potential model inputs were identified and discussed. Findings: Four scabies models were published: a Markov decision tree, two compartmental models, and an agent-based, network-dependent Monte Carlo model. None of the models specifically addressed crusted scabies, which is associated with high morbidity, mortality, and increased transmission. There is a lack of reliable, comprehensive information about scabies biology and the impact this disease has on patients and society. Discussion: Clinicians and health economists working in the field of scabies are encouraged to use the current review to inform disease transmission modelling and economic evaluations on interventions against scabies. [ABSTRACT FROM AUTHOR]

Background: In economic analyses of HIV interventions, South Africa is often used as a case in point, due to the availability of good epidemiological and programme data and the global relevance of its epidemic. Few analyses however use locally relevant cost data. We reviewed available cost data as part of the South African HIV Investment Case, a modelling exercise to inform the optimal use of financial resources for the country’s HIV programme. Methods: We systematically reviewed publication databases for published cost data covering a large range of HIV interventions and summarised relevant unit costs (cost per person receiving a service) for each. Where no data was found in the literature, we constructed unit costs either based on available information regarding ingredients and relevant public-sector prices, or based on expenditure records. Results: Only 42 (5%) of 1,047 records included in our full-text review reported primary cost data on HIV interventions in South Africa, with 71% of included papers covering ART. Other papers detailed the costs of HCT, MMC, palliative and inpatient care; no papers were found on the costs of PrEP, social and behaviour change communication, and PMTCT. The results informed unit costs for 5 of 11 intervention categories included in the Investment Case, with the remainder costed based on ingredients (35%) and expenditure data (10%). Conclusions: A large number of modelled economic analyses of HIV interventions in South Africa use as inputs the same, often outdated, cost analyses, without reference to additional literature review. More primary cost analyses of non-ART interventions are needed. [ABSTRACT FROM AUTHOR]

Background: In order to make informed decisions about how best to support children and young people with disabilities, effective strategies that facilitate active and meaningful participation in school are required. Clinical factors, diagnosis or impairments somewhat helpful in determining what should be provided in interventions. However, clinical factors alone will not offer a clear view of how to support participation. It is helpful then to look at wider psychosocial and environmental factors. The aim of this review was to synthesise evidence of psychosocial and environmental factors associated with school participation of 4–12 year old children with disabilities to inform the development of participation-fostering interventions. Methods: A systematic search and synthesis using realist methods was conducted of published research. Papers had to include consideration of psychosocial and/or environment factors for school participation of children with disabilities. The review was completed in accordance with the Realist and Meta-narrative Evidence Syntheses: Evolving Standards (RAMESES) and Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) guidelines. Papers were identified via Boolean search of the electronic databases MEDLINE, CINAHL, PhycINFO and ERIC (January 2006-October 2018). Appraisal focussed on contributions in terms of whether the articles are appropriate for the review (relevance) and research quality (rigour). Data were analyzed using content and thematic analysis methods using a realist framework. A narrative synthesis of results was reported. Results and implications: We identified 1828 papers in the initial search. Seventy two papers were included in the final synthesis. Synthesis of findings led to three overarching mechanisms representing psychosocial factors for children (1) identity (2) competence and (3) experience of mind and body. Environmental aspects (context) compromised five interrelated areas: (1) structures and organization, (2) peers, (3) adults, (4) space and (5) objects. Our synthesis provides insights on how professionals may organize efforts to improve children’s participation. Consideration of these findings will help to proactively deal with suboptimal participation outcomes. Development of theoretically determined assessments and interventions for management of school participation are now required. [ABSTRACT FROM AUTHOR]

Introduction: Stigma and discrimination (SAD) related to HIV compromise access and adherence to treatment and support programs among people living with HIV (PLHIV). The ambitious goal of ending the epidemic of HIV by 2030 set by the United Nations Joint Program of HIV/AIDS (UNAIDS) will thus only be achieved if HIV-related stigma and discrimination are reduced. The objective of this review was to locate, appraise and describe international literature reporting on interventions that addressed HIV-related SAD in healthcare settings. Methods: The databases searched were: Cumulative Index to Nursing and Allied Health (CINAHL), Excerpta Medica Database from Elsevier (EMBASE), PubMed and Psychological Information (PsycINFO) database. Two individuals independently appraised the quality of the papers using appraisal instruments from the Joanna Briggs Institute (JBI). Data were extracted from papers included in the review using the standardized data extraction tool from JBI. Quality of evidence for major outcomes was assessed using Grading of Recommendations, Assessment, Development and Evaluation (GRADE). Results: We retained 14 records reporting on eight studies. Five categories of SAD reduction (information-based, skills building, structural, contact-based and biomedical interventions) were identified. Training popular opinion leaders (POLs) resulted in significantly lower mean avoidance intent scores (MD = -1.87 [95% CI -2.05 to -1.69]), mean prejudicial attitude scores (MD = -3.77 [95% CI -5.4 to -2.09]) and significantly higher scores in mean compliance to universal precaution (MD = 1.65 [95% CI 1.41 to 1.89]) when compared to usual care (moderate quality evidence). The Summary of Findings table (SOF) is shown in . Conclusions: Evidence of moderate quality indicates that training popular opinion leaders is effective in reducing avoidance intent and prejudicial attitude and improving compliance to universal precaution. Very low quality evidence indicates that professionally-assisted peer group interventions, modular interactive training, participatory self-guided assessment and intervention, contact strategy combined with information giving and empowerment are effective in reducing HIV-related stigma.Further Randomized Controlled Trials (RCTs) are needed. Future trials need to use up-to-date and validated instruments to measure stigma and discrimination. [ABSTRACT FROM AUTHOR]

Introduction: Previous research has shown that statin adherence for the primary prevention of CVD is lower compared to secondary prevention populations. Therefore the aim of this systematic review was to review predictors of statin adherence for the primary prevention of CVD. Methods: A systematic search of papers published between Jan 1984 and May 2017 was conducted in PubMed, PsycINFO, EMbase and CINAHL databases. A study was eligible for inclusion if; 1) it was a study of the general population or of patients with familial hypercholesterolemia, hypertension, diabetes or arthritis; 2) statins were prescribed; 3) adherence was defined and measured as the extent to which patients followed their statin regimen during the period of prescription, and 4) it was an original trial or observational study (excluding case reports). A study was subsequently excluded if 1) results were not presented separately for primary prevention; 2) it was a trial of an intervention (for example patient education). Papers were reviewed by two researchers and consensus agreed with a third. A quality assessment (QA) tool was used to formally assess each included article. To evaluate the effect of predictors, data were quantitatively and qualitatively synthesised. Results: In total 19 studies met the inclusion criteria and nine were evaluated as high quality using the QA tool. The proportion of patients classed as “adherent” ranged from 17.8% to 79.2%. Potential predictors of statin adherence included traditional risk factors for CVD such as age, being male, diabetes and hypertension. Income associated with adherence more strongly in men than women, and highly educated men were more likely and highly educated women less likely to be adherent. Alcohol misuse and high BMI associated with non-adherence. There was no association between polypharmacy and statin adherence. The evidence base for the effect of other lifestyle factors and health beliefs on statin adherence was limited. Conclusion: Current evidence suggests that patients with more traditional risk factors for CVD are more likely to be adherent to statins. The implications for future research are discussed. [ABSTRACT FROM AUTHOR]

Introduction: The proportion of older persons in developing countries is increasing with no clear evidence of improvement in physical health. The aim of this paper was to examine the factors associated with older persons’ physical health in rural Uganda. Methods: This paper is based on a cross-sectional study of 912 older persons age 60 years and older across four major regions of Uganda. The study was conceptualized basing on World Health Organization quality of life BREF (WHOQOL-BREF). Analysis was done at three levels, that is, frequency distributions were generated to describe background characteristics of respondents and cross-tabulations were done to determine associations between dependent and each of the independent variables. Ordinal logistic regression was used to determine the predictors of physical health. Results: The likelihood of good physical health is high among older persons (Ops) who controlled their household assets (OR = 3.64; CI = 1.81–7.30) or the household assets controlled by their spouses (OR = 4.44; CI = 1.91–10.32) relative to those whose household assets were controlled by their children. There is high likelihood of good physical health among those who engage in physical activities (OR = 2.28; CI = 1.52–3.43) compared to those who do not. Conclusion: The findings have various policy implications, including creating an enabling environment and building capacities of older persons to remain in control of their household assets. Interventions focusing on deepening sensitization of older persons about importance of physical exercises could be a viable strategy for improving physical health of older persons. [ABSTRACT FROM AUTHOR]

Dementia is a neurological and cognitive condition that affects millions of people around the world. At any given time in the United Kingdom, 1 in 4 hospital beds are occupied by a person with dementia, while about 22% of these hospital admissions are due to preventable causes. In this paper we discuss using Internet of Things (IoT) technologies and in-home sensory devices in combination with machine learning techniques to monitor health and well-being of people with dementia. This will allow us to provide more effective and preventative care and reduce preventable hospital admissions. One of the unique aspects of this work is combining environmental data with physiological data collected via low cost in-home sensory devices to extract actionable information regarding the health and well-being of people with dementia in their own home environment. We have worked with clinicians to design our machine learning algorithms where we focused on developing solutions for real-world settings. In our solutions, we avoid generating too many alerts/alarms to prevent increasing the monitoring and support workload. We have designed an algorithm to detect Urinary Tract Infections (UTI) which is one of the top five reasons of hospital admissions for people with dementia (around 9% of hospital admissions for people with dementia in the UK). To develop the UTI detection algorithm, we have used a Non-negative Matrix Factorisation (NMF) technique to extract latent factors from raw observation and use them for clustering and identifying the possible UTI cases. In addition, we have designed an algorithm for detecting changes in activity patterns to identify early symptoms of cognitive decline or health decline in order to provide personalised and preventative care services. For this purpose, we have used an Isolation Forest (iForest) technique to create a holistic view of the daily activity patterns. This paper describes the algorithms and discusses the evaluation of the work using a large set of real-world data collected from a trial with people with dementia and their caregivers. [ABSTRACT FROM AUTHOR]

Quality circles or peer review groups, and similar structured small groups of 6–12 health care professionals meet regularly across Europe to reflect on and improve their standard practice. There is debate over their effectiveness in primary health care, especially over their potential to change practitioners’ behaviour. Despite their popularity, we could not identify broad surveys of the literature on quality circles in a primary care context. Our scoping review was intended to identify possible definitions of quality circles, their origins, and reported effectiveness in primary health care, and to identify gaps in our knowledge. We searched appropriate databases and included any relevant paper on quality circles published until December 2017. We then compared information we found in the articles to that we found in books and on websites. Our search returned 7824 citations, from which we identified 82 background papers and 58 papers about quality circles. We found that they originated in manufacturing industry and that many countries adopted them for primary health care to continuously improve medical education, professional development, and quality of care. Quality circles are not standardized and their techniques are complex. We identified 19 papers that described individual studies, one paper that summarized 3 studies, and 1 systematic review that suggested that quality circles can effectively change behaviour, though effect sizes varied, depending on topic and context. Studies also suggested participation may affirm self-esteem and increase professional confidence. Because reports of the effect of quality circles on behaviour are variable, we recommend theory-driven research approaches to analyse and improve the effectiveness of this complex intervention. [ABSTRACT FROM AUTHOR]

Background: Climate change and extreme temperatures pose increasing challenges to individuals and their health with older adults being one of the most vulnerable groups. The aim of this paper is to better understand the roles that tangible assets (e.g., physical or financial) and intangible assets (e.g., human or social) play in the way older adults adapt to extreme temperatures, the types of adaptive responses they implement, limits and constraints, as well opportunities for better adaptation. Rather than focusing exclusively on extremes of heat, or considering each type of asset in isolation, the important and novel contribution of this paper is to take an integrated and multi-seasonal qualitative and quantitative approach, that conjointly investigates all categories of assets in relation to the adaptations that independently-living older adults make to both extreme heat and extreme cold. Methods and findings: The paper examines the contribution of assets to adaptation to extreme temperatures among older adults living independently in their homes. An innovative mixed methods study with an inter-seasonal approach was implemented in Lisbon, Portugal with interviews and surveys during summer for extreme heat and winter for extreme cold. The ability of participants to adapt to extreme temperatures was found to be dependent on asset context and diversity, and the dynamics through which extreme temperatures enhanced or reduced the stock of assets available. As a result, participants engaged in activities of assets replacement, exchange or substitutions. Despite this, many participants recognised many constraints and limits to their ability to adapt and protect their health and well-being ranging from reduced income, high energy costs and lack of social networks. Opportunities for improving older adults’ adaptation were found to exist and strategies, action and investment have been identified by older adults which included life-long education, incentives to improve insulation and local activities. Conclusions: The paper suggests that the implementation of the proposed asset-based approach linking assets and adaptation to extreme temperatures, illustrates the key pathway that individuals, their families and carers, governments, policymakers, researchers and practitioners can follow to ensure effective adaptation and promote health and well-being. Supporting older adults’ adaptation to extreme temperatures is possible and can be complemented with efforts to reduce older adults’ vulnerability and building resilience to extreme temperatures. These findings pose concrete implications for policy and practice, including for example the need for implementation of measures and actions to reduce poverty, reduce energy costs, improve the quality of the housing stock and improve older adults’ social networks. [ABSTRACT FROM AUTHOR]

Background: In most low- and middle-income settings, national aggregate health data is the most consistently available source for policy-making and international comparisons. In the West Bank, the paper-based health information system with manual aggregations is transitioning to an individual-level data eRegistry for maternal and child health at the point-of-care. The aim of this study was to explore beforehand how routine health information systems indicators for antenatal care can change with the introduction of the eRegistry. Methods: Data were collected from clinical antenatal paper records of pregnancy enrollments for 2015 from 17 primary healthcare clinics, selected by probability sampling from five districts in the West Bank. We used the individual-level data from clinical records to generate routinely reported health systems indicators. We weighted the data to produce population-level estimates, and compared these indicators with aggregate routine health information systems reports. Results: Antenatal anemia screening at 36 weeks was 20% according to the clinical records data, compared to 52% in the routine reports. The clinical records data showed considerably higher incidences of key maternal conditions compared to the routine reports, including fundal height discrepancy (20% vs. 0.01%); Rh-negative blood group (6.8% vs. 1.4%); anemia with hemoglobin<9.5 g/dl (6% vs. 0.6%); and malpresentation at term (1.3% vs. 0.03%). Only about a sixth of cases with these conditions were referred according to guidelines to designated referral clinics. Conclusions: Differences between indicators from the clinical records data and routine health information systems reports can be attributed to human error, inconsistent denominators, and complexities of data processes. Key health systems indicators were prone to underestimations since their registration was dependent on referral of pregnant women. With a transition to individual-level data, as in the eRegistry under implementation, the public health authorities will be able to generate reliable health systems indicators reflective of the population’s health status. [ABSTRACT FROM AUTHOR]

Introduction: Stroke is a prominent cause of death, disability, and dementia in sub-Saharan Africa (SSA). The Stroke Investigative Research and Education Network works collaboratively with stroke survivors and individuals serving as community controls to comprehensively characterize the genomic, sociocultural, economic and behavioral risk factors for stroke in SSA. Purpose: In this paper, we aim to: i) explore the attitudes, beliefs, and practices related to stroke in Ghana and Nigeria using the process of qualitative description; and ii) propose actions for future research and community-based participation and education. Methods: Stroke survivors, their caregivers, health care professionals, and community representatives and faith-based leaders participated in one of twenty-six focus groups, which qualitatively explored community beliefs, attitudes and practices related to stroke in Ghana and Nigeria. Arthur Kleinman’s Explanatory Model of Illness and the Social Ecological Model guided the questions and/or thematic analysis of the qualitative data. We hereby describe our focus group methods and analyses of qualitative data, as well as the findings and suggestions for improving stroke outcomes. Results and discussion: The major findings illustrate the fears, causes, chief problems, treatment, and recommendations related to stroke through the views of the participants, as well as recommendations for working effectively with the SIREN communities. Findings are compared to SIREN quantitative data and other qualitative studies in Africa. As far as we are aware, this is the first paper to qualitatively explore and contrast community beliefs, attitudes, and practices among stroke survivors and their caregivers, community and faith-based leaders, and health professionals in multiple communities within Nigeria and Ghana. [ABSTRACT FROM AUTHOR]

The last several decades have witnessed a shift in the way in which news is delivered and consumed by users. With the growth and advancements in mobile technologies, the Internet, and Web 2.0 technologies users are not only consumers of news, but also producers of online content. This has resulted in a novel and highly participatory cyber-physical news awareness ecosystem that fosters digital activism, in which volunteers contribute content to online communities. While studies have examined the various components of this news awareness ecosystem, little is still known about how news media coverage (and in particular digital media) impacts digital activism. In order to address this challenge and develop a greater understanding of it, this paper focuses on a specific form of digital activism, that of the production of digital geographical content through crowdsourcing efforts. Using refugee camps from around the world as a case study, we examine the relationship between news coverage (via Google news), search trends (via Google trends) and user edit contribution patterns in OpenStreetMap, a prominent geospatial data crowdsourcing platform. In addition, we compare and contrast these patterns with user edit patterns in Wikipedia, a well-known non-geospatial crowdsourcing platform. Using Google news and Google trends to derive a measure of thematic public awareness, our findings indicate that digital activism bursts tend to take place during periods of sustained build-up of public awareness deficit or surplus. These findings are in line with two prominent mass communication theories: agenda setting and corrective action, and suggest the emergence of a novel stimulus-awareness-activism framework in today’s participatory digital age. Moreover, these findings further complement existing research examining the motivational factors that drive users to contribute to online collaborative communities. This paper brings us one step closer to understanding the underlying mechanisms that drive digital activism in particular in the geospatial domain. [ABSTRACT FROM AUTHOR]

Objective: There is a need for structure to achieve functional patient engagement within mental healthcare organizations, and for clarification on how to proceed on a strategic level. The aim of this paper is to shed light on the implementation of a strategic organizational structure for patient engagement in mental health by examining why and how to implement a structure, the organizational and environmental factors that facilitate or limit the process, and the perceived consequences of the implementation. Method: This paper evaluates the implementation of a strategic committee for patient engagement in a mental healthcare organization in Montreal (Quebec, Canada). The research was designed as a qualitative single case study using a deductive approach by means of a conceptual framework. Data sources consisted in ten semi-structured interviews, three focus groups, and organizational documents. Results: The strategic committee for patient engagement was implemented as a means to formalize patient partner participation, following the introduction of a vision of full citizenship. Important aspects of its implementation included its composition and role, the elaboration of a framework for patient partner participation, and finally, ongoing application and evaluation of the framework. Several facilitating factors were identified, including executive management support, leadership, and a vision behind the participation. Limiting factors mainly consisted of resistance towards patient participation and the existence of stigma. Consequences included increased and improved patient engagement, as well as reduced stigma within the organization. Conclusion: This study shows that the implementation of a strategic organizational structure for patient engagement is comprehensive. It further shows the importance of a vision and an articulate leadership involving several actors. Further research is needed regarding the impact of this type of strategic structure on a clinical level. [ABSTRACT FROM AUTHOR]

This paper re-examines health-growth relationship using an unbalanced panel of 17 advanced economies for the period 1870–2013 and employs panel generalised method of moments estimator that takes care of endogeneity issues, which arise due to reverse causality. We utilise macroeconomic data corresponding to inflation, government expenditure, trade and schooling in sample countries that takes care of omitted variable bias in growth regression. With alternate model specifications, we show that population health proxied by life expectancy exert a positive and significant effect on both real income per capita as well as growth. Our results are in conformity with the existing empirical evidence on the relationship between health and economic growth, they, however, are more robust due to the presence of long-term data, appropriate econometric procedure and alternate model specifications. We also show a strong role of endogeneity in driving standard results in growth empirics. In addition to life expectancy, other constituent of human capital, education proxied by schooling is also positively associated with real per capita income. Policy implication that follows from this paper is that per capita income can be boosted through focussed policy attention on population health. The results, however, posit differing policy implications for advanced and developing economies. [ABSTRACT FROM AUTHOR]

Mothers, caregivers, and healthcare providers in 163 countries have used paper and electronic home-based records (HBRs) to facilitate primary care visit. These standardized records have the potential to empower women, improve the quality of care for mothers and children and reduce health inequities. This review examines experiences of women, caregivers and providers with home-based records for maternal and child health and seeks to explore the feasibility, acceptability, affordability and equity of these interventions. We systematically searched MEDLINE, MEDLINE In-Process, MEDLINE Ahead of Print, Embase, CINAHL, ERIC, and PsycINFO for articles that were published between January 1992 and December 2017. We used the CASP checklist to assess study quality, a framework analysis to support synthesis, and GRADE-CERQual to assess the confidence in the key findings. Of 7,904 citations, 19 studies met our inclusion criteria. In these studies, mothers, caregivers and children shared HBR experiences in relation to maternal and child health which facilitated the monitoring of immunisations and child growth and development. Participants’ reports of HBRs acting as a point of commonality between patient and provider offer an explanation for their perceptions of improved communication and patient-centered care, and enhanced engagement and empowerment during pregnancy and childcare. Healthcare providers and nurses reported that the home-based record increased their feeling of connection with their patients. Although there were concerns around electronic records and confidentiality, there were no specific concerns reported for paper records. Mothers and other caregivers see home based records as having a pivotal role in facilitating primary care visits and enhancing healthcare for their families. The records’ potential could be limited by users concerns over confidentiality of electronic home-based records, or shortcomings in their design. Health systems should seize the opportunity HBRs provide in empowering women, especially in the contexts of lower literacy levels and weak health care delivery systems. [ABSTRACT FROM AUTHOR]

Objective: To explore intersections of social determinants of maternal healthcare utilization using the Classification and Regression Trees (CART) algorithm which is a machine-learning method used to construct prediction models. Methods: Institutional review board approval for this study was granted from Public Health Service—Ethical Review Board (PHS-ERB) and from the Health Ministry Screening Committee (HMSC) facilitated by Indian Council for Medical Research (ICMR). IRB review and approval for the current analyses was obtained from University of California, San Diego. Cross-sectional data were collected from women with children aged 0–11 months (n = 5,565) from rural households in 25 districts of Uttar Pradesh, India. Participants were surveyed on maternal healthcare utilization including registration of pregnancy (model-1), receipt of antenatal care (ANC) during pregnancy (model-2), and delivery at health facilities (model -3). Social determinants of health including wealth, social group, literacy, religion, and early age at marriage were captured during the survey. The Classification and Regression Tree (CART) algorithm was used to explore intersections of social determinants of healthcare utilization. Results: CART analyses highlight the intersections, particularly of wealth and literacy, in maternal healthcare utilization in Uttar Pradesh. Model-1 documents that women who are poorer, illiterate and Muslim are less likely to have their pregnancies registered (71.4% vs. 86.0% in the overall sample). Model-2 documents that poorer, illiterate women had the lowest ANC coverage (37.7% vs 45% in the overall sample). Model-3, developed for deliveries at health facilities, highlighted that illiterate and poor women have the lowest representation among facility deliveries (59.6% vs. 69% in the overall sample). Conclusion: This paper explores the interactions between determinants of maternal healthcare utilization indicators. The findings in this paper highlights that the interaction of wealth and literacy can play a very strong role in accentuating or diminishing healthcare utilization among women. The study also reveals that religion and women’s age at marriage also interact with wealth and literacy to create substantial disparities in utilization. The study provides insights into the effect of intersections of determinants, and highlights the importance of using a more nuanced understanding of the impact of co-occurring forms of marginalization to effectively tackle inequities in healthcare utilization. [ABSTRACT FROM AUTHOR]

Racial segregation, and in particular school segregation, likely plays an important role in affecting health outcomes. To examine this connection, this paper explores the relationship between the end of court-ordered school desegregation and preterm births among Blacks using birth certificate information between 1992 and 2002 (n = 183,178). The end of court-ordered oversight has important implications for the level of racial segregation in schools: If residential segregation remains high, neighborhood-based student assignment plans would naturally increase school segregation. A rise in school segregation may lead to worse educational, labor, and health outcomes among Blacks. Using multiple difference-in-differences framework that exploits variation in exposure to schools that declared unitary status, it finds that school districts’ release from court oversight is associated with a 0.8 percentage point increase in preterm births among Black mothers. This paper contributes to literature that finds that the end of court-ordered school desegregation in the 1990s have negative implications for Blacks. More research should be conducted to understand the causal relationship between school segregation and infant health. [ABSTRACT FROM AUTHOR]

Background: Over the past two decades, the focus of mental health care has shifted from institutionalisation to community-based programs and short hospital stays. This change means that there is an increased role for caregivers, mostly family members, in managing persons with mental illness. Although there is evidence to support the benefits of deinstitutionalisation of mental health care, there are also indications of substantial burden experienced by caregivers; the evidence of which is limited in sub-Saharan Africa. However, knowledge of the nature and extent of this burden can inform the planning of mental health services that will not only benefit patients, but also caregivers and households. Objective: To systematically review the available evidence on the economic burden of severe mental illness on primary family caregivers in sub-Saharan Africa. Methods: A comprehensive search was conducted in Pubmed, CINAHL, Econlit and Web of Science with no date limitations up to September 2016 using keywords such as "burden", "cost of illness" and "economic burden" to identify relevant published literature. Articles were appraised using a standardised data extraction tool covering themes such as physical, psychological and socioeconomic burden. Results: Seven papers were included in the review. Caregivers were mostly family members with a mean age of 46.34, female and unemployed. Five out of seven studies (71%) estimated the full economic burden of severe mental illness on caregivers. The remainder of studies just described the caregiver burden. All seven papers reported moderate to severe caregiver burden characterised by financial constraint, productivity loss and lost employment. The caregiver’s level of income and employment status, severity of patient's condition and duration of mental illness were reported to negatively affect the economic burden experienced by caregivers. Conclusion: There is paucity of studies reporting the burden of severe mental illness on caregivers in sub-Saharan Africa. Further research is needed to present the nature and extent of this burden to inform service planning and policymaking. [ABSTRACT FROM AUTHOR]

Background: Tuberculosis (TB) incidence in South Africa is among the highest globally. Initial loss to follow-up (ILFU), defined as not starting on TB treatment within 28 days of testing positive, is undermining control efforts. We assessed the feasibility, acceptability, and potential of a mHealth application to reduce ILFU. Methods: An mHealth application was developed to capture patients TB investigation data, provide results and monitor treatment initiation. This was implemented in two primary health clinics (PHC) in inner-city Johannesburg. Feasibility was assessed by comparing documentation of personal details, specimen results for same individuals during implementation period (paper register and Mhealth application). Effectiveness was assessed by comparing proportion of patients with results within 48 hours, and proportion started on treatment within 28 days of testing TB positive during pre- implementation (paper register) and implementation (mHealth application) periods. In-depth interviews with patients and providers were conducted to assess acceptability of application. Results: Pre-implementation, 457 patients were recorded in paper registers [195 (42.7%) male, median age 34 years (interquartile range IQR (28–40), 45 (10.5%) sputum Xpert positive]. During implementation, 319 patients were recorded in paper register and the mHealth application [131 (41.1%) male, median age 32 years (IQR 27–38), 33 (10.3%) sputum Xpert positive]. The proportion with complete personal details: [mHealth 95.0% versus paper register 94.0%, (p = 0.54)] and proportion with documented results: [mHealth 97.4% versus paper register 97.8%, (p = 0.79)] were not different in the two methods. The proportion of results available within 48 hours: [mHealth 96.8% versus paper register 68.6%), (p <0.001)], and the proportion on treatment within 28 days [mHealth 28/33 (84.8%) versus paper register 30/44 (68.2%), (p = 0.08)] increased during implementation but was not statistically significant. In-depth interviews showed that providers easily integrated the mHealth application into routine TB investigation and patients positively received the delivery of results via text message. Time from sputum collection to TB treatment initiation decreased from 4 days (pre-implementation) to 3 days but was not statistically significant. Conclusions: We demonstrated that implementation of the mHealth application was feasible, acceptable to health care providers and patients, and has potential to reduce the time to TB treatment initiation and ILFU in PHC settings. [ABSTRACT FROM AUTHOR]

Introduction: Homebirths are common in low and middle income countries and are associated with poor child survival. We assessed the feasibility of using smartphones by village health workers for pregnancy registration and the effectiveness of health text messages (SMS) sent to pregnant women through village health workers in reducing homebirths in rural Uganda. Methods: A non-randomised intervention study was undertaken in 26 villages. In the intervention arm, village health workers registered pregnant women (n = 262) in 13 villages using a smartphone app (doForm) and paper forms and gestation age-timed SMS were sent through village health workers to the pregnant women. In 13 control villages, (n = 263) pregnant women were registered on paper forms only and no SMS was sent. The main outcome was place of birth measured through a self-report. Logistic regression with generalised estimating equations was used to explore the effect of the intervention. Results: Comparing 795 corresponding data fields on phone and paper revealed that numeric variable fields were 86%-95% similar while text fields were 38%-48% similar. Of the 525 pregnant women followed, 83 (15.8%) delivered at home. In the adjusted analysis, the intervention was associated with lower odds of homebirths [AOR = 0.38, 95%CI (0.15–0.97)]. Muslim religion [AOR = 4.0, 95%CI (1.72–9.34)], primary or no maternal education [AOR = 2.51, 95%CI (1.00–6.35)] and health facility distance ≥ 2 km [AOR = 2.26, 95%CI (0.95–5.40)] were independently associated with homebirths. Conclusion: Village health workers can register pregnant women at home using phones and relay gestation age specific SMS to them to effectively reduce homebirths. [ABSTRACT FROM AUTHOR]

Norwegian Health authorities recommend solid food to be introduced between child age 4–6 months, depending on both the mother´s and infant’s needs. The aim of this paper is to describe timing of complementary feeding in a current sample of Norwegian mother/infant-dyads and explore potential associations between timing of introduction to solid foods and a wide range of maternal and infant characteristics known from previous literature to influence early feeding interactions. The paper is based on data from the Norwegian randomized controlled trial Early Food for Future Health. In 2016, a total of 715 mothers completed a web-based questionnaire at child age 5.5 months. We found that 5% of the infants were introduced to solid food before 4 months of age, while 14% were not introduced to solid food at 5.5 months of age. Introduction of solid food before 4 months of age was associated with the infant not being exclusive breastfed the first month, receiving only formula milk at 3 months, the mother being younger, not married/cohabitant, smoking, less educated and having more economic difficulties. Not being introduced to solid food at 5.5 months was associated with the infant being a girl, being exclusive breastfed the first month, receiving only breastmilk at 3 months, the mother being older, married and having 3 or more children. This study shows that there are still clear socioeconomic differences regarding timing of complementary feeding in Norway. Infants of younger, less educated and smoking mothers are at higher risk of not being fed in compliance with the official infant feeding recommendations. Our findings emphasize the importance of targeting socioeconomically disadvantaged mothers for support on healthy feeding practices focusing on the infant`s needs to prevent early onset of social inequalities in health. [ABSTRACT FROM AUTHOR]

Context: In response to political and social factors over the last sixty years mental health systems internationally have endeavoured to transfer the delivery of care from hospitals into community settings. As a result, there has been increased emphasis on the need for better quality care planning and care coordination between hospital services, community services and patients and their informal carers. The aim of this systematic review of international research is to explore which interventions have proved more or less effective in promoting personalized, recovery oriented care planning and coordination for community mental health service users. Methods: A systematic meta-narrative review of research from 1990 to the present was undertaken. From an initial return of 3940 papers a total of 50 research articles fulfilled the inclusion criteria, including research from the UK, Australia and the USA. Findings: Three research traditions are identified consisting of (a) research that evaluates the effects of government policies on the organization, management and delivery of services; (b) evaluations of attempts to improve organizational and service delivery efficiency; (c) service-users and carers experiences of community mental health care coordination and planning and their involvement in research. The review found no seminal papers in terms of high citation rates, or papers that were consistently cited over time. The traditions of research in this topic area have formed reactively in response to frequent and often unpredictable policy changes, rather than proactively as a result of intrinsic academic or intellectual activity. This may explain the absence of seminal literature within the subject field. As a result, the research tradition within this specific area of mental health service delivery has a relatively short history, with no one dominant researcher or researchers, tradition or seminal studies amongst or across the three traditions identified. Conclusions: The research findings reviewed suggests a gap has existed internationally over several decades between policy aspirations and service level interventions aimed at improving personalised care planning and coordination and the realities of everyday practices and experiences of service users and carers. Substantial barriers to involvement are created through poor information exchange and insufficient opportunities for care negotiation. [ABSTRACT FROM AUTHOR]

Background: Due to the disease’s progressive nature, advance care planning (ACP) is recommended for people with early stage dementia. General practitioners (GPs) should initiate ACP because of their longstanding relationships with their patients and their early involvement with the disease, however ACP is seldom applied. Aim: To determine the barriers and facilitators faced by GPs related to ACP with people with dementia. Data sources: We systematically searched the relevant databases for papers published between January 1995 and December 2016, using the terms: primary healthcare, GP, dementia, and ACP. We conducted a systematic integrative review following Whittemore and Knafl’s method. Papers containing empirical data about GP barriers and/or facilitators regarding ACP for people with dementia were included. We evaluated quality using the Mixed-Method-Appraisal-Tool and analyzed data using qualitative content analysis. Results: Ten qualitative, five quantitative, and one mixed-method paper revealed four themes: timely initiation of ACP, stakeholder engagement, important aspects of ACP the conversation, and prerequisites for ACP. Important barriers were: uncertainty about the timing of ACP, how to plan for an uncertain future, lack of knowledge about dementia, difficulties assessing people with dementia’s decisional capacities, and changing preferences. Facilitators for ACP were: an early start when cognitive decline is still mild, inclusion of all stakeholders, and discussing social and medical issues aimed at maintaining normal life. Conclusion: Discussing future care is difficult due to uncertainties about the future and the decisional capacities of people with dementia. Based on the facilitators, we recommend that GPs use a timely and goal-oriented approach and involve all stakeholders. ACP discussions should focus on the ability of people with dementia to maintain normal daily function as well as on their quality of life, instead of end-of-life-discussions only. GPs need training to acquire knowledge and skills to timely initiate collaborative ACP discussions. [ABSTRACT FROM AUTHOR]

Objective: Gestural interfaces allow accessing and manipulating Electronic Medical Records (EMR) in hospitals while keeping a complete sterile environment. Particularly, in the Operating Room (OR), these interfaces enable surgeons to browse Picture Archiving and Communication System (PACS) without the need of delegating functions to the surgical staff. Existing gesture based medical interfaces rely on a suboptimal and an arbitrary small set of gestures that are mapped to a few commands available in PACS software. The objective of this work is to discuss a method to determine the most suitable set of gestures based on surgeon’s acceptability. To achieve this goal, the paper introduces two key innovations: (a) a novel methodology to incorporate gestures’ semantic properties into the agreement analysis, and (b) a new agreement metric to determine the most suitable gesture set for a PACS. Materials and methods: Three neurosurgical diagnostic tasks were conducted by nine neurosurgeons. The set of commands and gesture lexicons were determined using a Wizard of Oz paradigm. The gestures were decomposed into a set of 55 semantic properties based on the motion trajectory, orientation and pose of the surgeons’ hands and their ground truth values were manually annotated. Finally, a new agreement metric was developed, using the known Jaccard similarity to measure consensus between users over a gesture set. Results: A set of 34 PACS commands were found to be a sufficient number of actions for PACS manipulation. In addition, it was found that there is a level of agreement of 0.29 among the surgeons over the gestures found. Two statistical tests including paired t-test and Mann Whitney Wilcoxon test were conducted between the proposed metric and the traditional agreement metric. It was found that the agreement values computed using the former metric are significantly higher (p < 0.001) for both tests. Conclusions: This study reveals that the level of agreement among surgeons over the best gestures for PACS operation is higher than the previously reported metric (0.29 vs 0.13). This observation is based on the fact that the agreement focuses on main features of the gestures rather than the gestures themselves. The level of agreement is not very high, yet indicates a majority preference, and is better than using gestures based on authoritarian or arbitrary approaches. The methods described in this paper provide a guiding framework for the design of future gesture based PACS systems for the OR. [ABSTRACT FROM AUTHOR]

Animal diseases are global issues affecting the productivity and financial profitability of affected farms. Johne’s disease is distributed on farms worldwide and is an endemic contagious bacterial infection in ruminants caused by Mycobacterium avium subspecies paratuberculosis. In cattle, the clinical disease manifests itself as chronic enteritis resulting in reduced production, weight loss, and eventually death. Johne’s disease is prevalent in the UK, including Scotland. Direct costs and losses associated with Johne’s disease have been estimated in previous research, confirming an important economic impact of the disease in UK herds. Despite this, the distributional impact of Johne’s disease among milk consumers and producers in Scotland has not been estimated. In this paper, we evaluate the change in society’s economic welfare, namely to dairy producers (i.e. infected and uninfected herds) and milk consumers in Scotland induced by the introduction of Johne’s disease in the national Scottish dairy herd. At the national-level, we conclude that the economic burden falls mainly on producers of infected herds and, to a lesser extent, milk consumers, while producers of uninfected herds benefit from the presence of Johne’s. An infected producer’s loss per cow is approximately two times larger in magnitude than that of an uninfected producer’s gain. Such economic welfare estimates are an important comparison of the relative costs of national herd prevalence and the wider economic welfare implications for both producers and consumers. This is particularly important from a policy, public good, cost sharing, and human health perspective. The economic welfare framework presented in this paper can be applied to other diseases to examine the relative burden of society’s economic welfare of alternative livestock disease scenarios. In addition, the sensitivity analysis evaluates uncertainty in economic welfare given limited data and uncertainty in the national herd prevalence, and other input parameters, associated with Johne’s disease in Scotland. Therefore, until the prevalence of Johne’s is better understood, the full economic cost to Scottish dairy herds remains uncertain but in the meantime the sensitivity analysis evaluates the robustness of economic welfare to such uncertainties. [ABSTRACT FROM AUTHOR]

Purpose: The 2014 outbreak of Ebola virus disease (EVD) in West Africa was the largest in history. Starting in September 2014, International Medical Corps (IMC) operated five Ebola treatment units (ETUs) in Sierra Leone and Liberia. This paper explores how future infectious disease outbreak facilities in resource-limited settings can be planned, organized, and managed by analyzing data collected on water, sanitation, and hygiene (WASH) and infection prevention control (IPC) protocols. Design/Methodology/Approach: We conducted a retrospective cohort study by analyzing WASH/IPC activity data routinely recorded on paper forms or white boards at ETUs during the outbreak and later merged into a database from two IMC-run ETUs in Sierra Leone between December 2014 and December 2015. Findings: The IMC WASH/IPC database contains data from over 369 days. Our results highlight parameters key to designing and maintaining an ETU. High concentration chlorine solution usage was highly correlated with both daily patient occupancy and high-risk zone staff entries; low concentration chlorine usage was less well explained by these measures. There is high demand for laundering and disinfecting of personal protective equipment (PPE) on a daily basis and approximately 1 (0–4) piece of PPE is damaged each day. Research limitations/Implications: Lack of standardization in the type and format of data collected at ETUs made constructing the WASH/IPC database difficult. However, the data presented here may help inform humanitarian response operations in future epidemics. [ABSTRACT FROM AUTHOR]

Background: Despite several decades of evidence supporting the benefits of taking medications in various diseases and healthcare settings, a significant proportion of prescribed treatments are not taken. This review sought to synthesise qualitative research exploring experiences of medication taking around the world, and to determine whether there were consistent messages arising from these studies. Methods and findings: 5 databases (MEDLINE, PsycINFO, EMBASE, SCOPUS, CINAHL) were systematically searched to identify published research papers using qualitative methodologies, which explored medication-taking experiences in patients, citizens, carers, relatives and clinicians. Data were extracted independently by at least two clinician reviewers. Implications for practice from individual papers were charted and coded using thematic content analysis. These were then cross-tabulated with research paper categories to explore emergent patterns with particular implications for practice. 192 papers from 34 different countries were included in the review. Implications for practice fitted into 11 categories: increase family involvement, increase clinician involvement, promote personalised management, address practical barriers, provide ongoing support, promote self-management, adopt a patient-centred approach, improve patient education, address system barriers, increase access to non-prescribing clinicians and improve clinician training. These implications for practice were generally evenly spread across research paper categories. Conclusions: Implications for practice from the published qualitative literature exploring medication-taking are notably consistent across research methods, disease categories and geographical settings. More recent clinical trials of interventions to improve adherence have started to draw on these findings by focussing on improving clinical interactions and involving patients in healthcare decisions. Promoting patient education and self-management have been widely advocated, and improvements at a system level have been frequently cited in studies from developing countries and those relating to communicable diseases. Regardless of the setting, clinicians and policymakers around the world can focus efforts to improve medication-taking by considering a number of consistently emerging findings. [ABSTRACT FROM AUTHOR]

Introduction: Non-medical prescribing has the potential to deliver innovative healthcare within limited finances. However, uptake has been slow, and a proportion of non-medical prescribers do not use the qualification. This systematic review aimed to describe the facilitators and barriers to non-medical prescribing in the United Kingdom. Methods: The systematic review and thematic analysis included qualitative and mixed methods papers reporting facilitators and barriers to independent non-medical prescribing in the United Kingdom. The following databases were searched to identify relevant papers: AMED, ASSIA, BNI, CINAHL, EMBASE, ERIC, MEDLINE, Open Grey, Open access theses and dissertations, and Web of Science. Papers published between 2006 and March 2017 were included. Studies were quality assessed using a validated tool (QATSDD), then underwent thematic analysis. The protocol was registered with PROSPERO (CRD42015019786). Results: Of 3991 potentially relevant identified studies, 42 were eligible for inclusion. The studies were generally of moderate quality (83%), and most (71%) were published 2007–2012. The nursing profession dominated the studies (30/42). Thematic analysis identified three overarching themes: non-medical prescriber, human factors, and organisational aspects. Each theme consisted of several sub-themes; the four most highly mentioned were ‘medical professionals’, ‘area of competence’, ‘impact on time’ and ‘service’. Sub-themes were frequently interdependent on each other, having the potential to act as a barrier or facilitator depending on circumstances. Discussion: Addressing the identified themes and subthemes enables strategies to be developed to support and optimise non-medical prescribing. Further research is required to identify if similar themes are encountered by other non-medical prescribing groups than nurses and pharmacists. [ABSTRACT FROM AUTHOR]

Background: In practical research, it was found that most people made health-related decisions not based on numerical data but on perceptions. Examples include the perceptions and their corresponding linguistic values of health risks such as, smoking, syringe sharing, eating energy-dense food, drinking sugar-sweetened beverages etc. For the sake of understanding the mechanisms that affect the implementations of health-related interventions, we employ fuzzy variables to quantify linguistic variable in healthcare modeling where we employ an integrated system dynamics and agent-based model. Methodology: In a nonlinear causal-driven simulation environment driven by feedback loops, we mathematically demonstrate how interventions at an aggregate level affect the dynamics of linguistic variables that are captured by fuzzy agents and how interactions among fuzzy agents, at the same time, affect the formation of different clusters(groups) that are targeted by specific interventions. Results: In this paper, we provide an innovative framework to capture multi-stage fuzzy uncertainties manifested among interacting heterogeneous agents (individuals) and intervention decisions that affect homogeneous agents (groups of individuals) in a hybrid model that combines an agent-based simulation model (ABM) and a system dynamics models (SDM). Having built the platform to incorporate high-dimension data in a hybrid ABM/SDM model, this paper demonstrates how one can obtain the state variable behaviors in the SDM and the corresponding values of linguistic variables in the ABM. Conclusions: This research provides a way to incorporate high-dimension data in a hybrid ABM/SDM model. This research not only enriches the application of fuzzy set theory by capturing the dynamics of variables associated with interacting fuzzy agents that lead to aggregate behaviors but also informs implementation research by enabling the incorporation of linguistic variables at both individual and institutional levels, which makes unstructured linguistic data meaningful and quantifiable in a simulation environment. This research can help practitioners and decision makers to gain better understanding on the dynamics and complexities of precision intervention in healthcare. It can aid the improvement of the optimal allocation of resources for targeted group (s) and the achievement of maximum utility. As this technology becomes more mature, one can design policy flight simulators by which policy/intervention designers can test a variety of assumptions when they evaluate different alternatives interventions. [ABSTRACT FROM AUTHOR]

Background: In the Cameroon, previous efforts to identify Buruli ulcer (BU) through the mobilization of community health workers (CHWs) yielded poor results. In this paper, we describe the successful creation of a BU community of practice (BUCOP) in Bankim, Cameroon composed of hospital staff, former patients, CHWs, and traditional healers. Methods and principle findings: All seven stages of a well-defined formative research process were conducted during three phases of research carried out by a team of social scientists working closely with Bankim hospital staff. Phase one ethnographic research generated interventions tested in a phase two proof of concept study followed by a three- year pilot project. In phase three the pilot project was evaluated. An outcome evaluation documented a significant rise in BU detection, especially category I cases, and a shift in case referral. Trained CHW and traditional healers initially referred most suspected cases of BU to Bankim hospital. Over time, household members exposed to an innovative and culturally sensitive outreach education program referred the greatest number of suspected cases. Laboratory confirmation of suspected BU cases referred by community stakeholders was above 30%. An impact and process evaluation found that sustained collaboration between health staff, CHWs, and traditional healers had been achieved. CHWs came to play a more active role in organizing BU outreach activities, which increased their social status. Traditional healers found they gained more from collaboration than they lost from referral. Conclusion/ Significance: Setting up lines of communication, and promoting collaboration and trust between community stakeholders and health staff is essential to the control of neglected tropical diseases. It is also essential to health system strengthening and emerging disease preparedness. The BUCOP model described in this paper holds great promise for bringing communities together to solve pressing health problems in a culturally sensitive manner. [ABSTRACT FROM AUTHOR]

Background: Middle ear disease (otitis media) is endemic among Aboriginal and Torres Strait Islander children in Australia and represents an important cause of hearing loss. The disease is the result of a mix of biological, environmental and host risk factors that interact in complex, non-linear ways along a dynamic continuum. As such, it is generally recognised that a holistic, systems approach is required to reverse the high rates of otitis media in Aboriginal and Torres Strait Islander children. The objective of this paper is to examine the alignment between efforts designed to address otitis media in Aboriginal and Torres Strait Islander children in Queensland, Australia and core concepts of systems thinking. This paper’s overall purpose is to identify which combination of activities, and at which level, hold the potential to facilitate systems changes to better support ear health among Aboriginal and Torres Strait Islander children. Methods: We began with a review of documents identified in consultation with stakeholders and an online search. In addition, key informants were invited to participate in an online survey and a face-to-face or phone interview. Qualitative interviews using a semi-structured interview guide were used to explore survey responses in more depth. We also undertook interviews at the community level to elicit a diverse range of views. Ideas, statements or activities reported in the documents and interviews as being performed under the Intervention Level Framework were identified using qualitative thematic and content analysis. A quantitative descriptive analysis was also undertaken, whereby data was extracted into an Excel spreadsheet and coded under the relevant strategic directions and performance indicators of the Framework. Subsequently, we coded activities against the five-level intervention framework developed by Malhi and colleagues, that is: 1) paradigm; 2) goals; 3) system structure; 4) feedback and delays; and 5) structural elements. Results: Overall, twenty documents were reviewed. We examined surveys and interviews with six key informants. Twenty-four individual and 3 group interviews were conducted across central and community level informants. One hundred and four items were coded from the 20 documents and 156 items from interview data. For both data sets, the majority of activities were coded at the structural elements level. The results suggested three key areas where further work is needed to drive sustained improvements: 1) build the governance structures needed for paradigm shift to achieve a multi-sectoral approach; 2) develop shared system level goals; 3) develop system-wide feedback processes. Conclusions: Sustained progress in improving ear health within Aboriginal and Torres Strait Islander children requires a holistic, system-wide approach. To advance such work, governance structures for multi-sectoral collaboration including the development of joint goals and monitoring and feedback are required. Intervening at these higher leverage points could have a profound effect on persistent public health issues. [ABSTRACT FROM AUTHOR]

This paper addresses patient-reported outcomes (PROs) and telemonitoring in congestive heart failure (CHF), both increasingly important topics. The interest in CHF trials is shifting from hard end-points such as hospitalization and mortality, to softer end-points such health-related quality of life. However, the relation of these softer end-points to objective parameters is not well studied. Telemonitoring is suitable for collecting both patient-reported outcomes and objective parameters. Most telemonitoring studies, however, do not take full advantage of the available sensor technology and intelligent data analysis. The Chiron clinical observational study was performed among 24 CHF patients (17 men and 7 women, age 62.9 ± 9.4 years, 15 NYHA class II and 9 class III, 10 of ishaemic, aetiology, 6 dilated, 2 valvular, and 6 of multiple aetiologies or cardiomyopathy) in Italy and UK. A large number of physiological and ambient parameters were collected by wearable and other devices, together with PROs describing how well the patients felt, over 1,086 days of observation. The resulting data were mined for relations between the objective parameters and the PROs. The objective parameters (humidity, ambient temperature, blood pressure, SpO2, and sweeting intensity) could predict the PROs with accuracies up to 86% and AUC up to 0.83, making this the first report providing evidence for ambient and physiological parameters to be objectively related to PROs in CHF patients. We also analyzed the relations in the predictive models, gaining some insights into what affects the feeling of health, which was also generally not attempted in previous investigations. The paper strongly points to the possibility of using PROs as primary end-points in future trials. [ABSTRACT FROM AUTHOR]