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Objectives A thorough understanding of user needs and behavioural intent-to-use underpins the development of a responsive health information system. This study aimed to examine health workers’ intent-to-use an electronic health record (EHR) system in an urban, rural and remote setting in the Philippines.Methods Following the Unified Theory of Acceptance and Use of Technology framework, user acceptance and the factors influencing intent-to-use the EHR were examined through a self-administered questionnaire. A total of 128 EHR users, comprising physicians, nurses, midwives, barangay health workers and administrative staff, were surveyed. Median scores for each domain were compared across the sites using the Kruskal-Wallis test. Ridge regression analysis was used to identify factors associated with behavioural intent-to-use.Results Over 94% of users across all sites reported their intent-to-use the EHR in the near future. Of the seven predictor variables examined, only self-efficacy was found to be significantly associated with behavioural intent-to-use. Intent-to-use the EHR increased by 31% (p=0.007) for each unit increase in self-efficacy score among participants.Discussion Acceptance was high across the three sites, with self-efficacy being a predictor of intent-to-use the technology. This suggests that users are more likely to adopt an EHR if they believe they have the capacity to successfully navigate the technology and perform their designated tasks with it.Conclusion Co-producing interventions with primary care providers is crucial in sustaining EHR systems. Rather than developing a technology based on the surveillance needs of policymakers, an EHR developed from the grassroots was shown to be well-received by end-users.

Constraining the primary growth channel of supermassive black holes (SMBHs) remains one the most actively debated questions in the context of cosmological structure formation. Owing to the expected connection between SMBH spin parameter evolution and the accretion and merger history of individual black holes, population spin measurements offer a rare observational window into the cosmic growth of SMBHs. As of today, the most common method for estimating SMBH spin relies on modeling the relativistically broaden atomic profiles in the reflection spectrum observed in X-rays. In this paper, we study the observational requirements needed to confidently distinguish between the primary SMBH growth channels based on their distinct spin-mass distributions predicted by the Horizon-AGN cosmological simulation. Indoing so, we characterize outstanding limitations associated with the existing measurements and discuss the landscape of future observational campaigns which could be planned and executed with future X-ray observatories. We focus our attention on the High-Energy X-ray Probe (HEX-P), a proposed probe-class mission designed to serve the high-energy community in the 2030s.

Objectives This study measured changes in patient satisfaction levels before and after the introduction of primary care system strengthening interventions in urban, rural, and remote sites in the Philippines.Methods A previously validated 16-item questionnaire was distributed to 200 patients per site before implementation of interventions and to a different set of 200 patients 1 year after implementation. We compared the percentage change in highly satisfied patients per site before and after implementing interventions using a two-proportion Z-test.Results The urban site had a significant increase in patient satisfaction in 13 survey items, which corresponded to the domains of healthcare availability, service efficiency, technical competency and health communication. The rural site had a significant increase in six survey items, which corresponded to the domains of service efficiency, environment, location, health communication and handling. The remote site had a decrease in patient satisfaction in 10 survey items, with a significant increase in only 4 items under the domains of healthcare availability and handling.Conclusion Our findings support the ‘inverse equity hypothesis’, where well-resourced urban communities quickly adopt complex health interventions while rural and remote settings experience delays in effectively meeting patient needs and system demands. Extended intervention periods and targeted strategies may be necessary to impact patient satisfaction in underserved areas considerably.

Introduction Strengthening primary care helps address health inequities that continue to persist in the Philippines. The Philippine Primary Care Studies pilot-tested interventions to improve the primary care system. One intervention was the provision of a free subscription to an electronic decision support application called UpToDate (UTD) for primary care providers (PCPs), including doctors, nurses, midwives and community health workers (CHWs). This study aimed to (1) assess the feasibility of using UTD as information source for PCPs in urban, rural and remote settings, (2) determine the acceptability of UTD as an information source for PCPs and (3) examine the impact of UTD access on PCP clinical decision-making.Methods Four focus group discussions (FGDs) and two key informant interviews (KII) were conducted to gather insights from 30 PCPs. Thematic analysis through coding in NVivo V.12 was done using the technology acceptance model (TAM) as a guiding framework.Results All PCPs had positive feedback regarding UTD use because of its comprehensiveness, accessibility, mobility and general design. The participants relayed UTD’s benefit for point-of-contact use, capacity-building and continuing professional development. PCPs across the three sites, including CHWs with no formal medical education, were able to provide evidence-based medical advice to patients through UTD. However, external factors in these settings impeded the full integration of UTD in the PCPs’ workflow, including poor internet access, unstable sources of electricity, lack of compatible mobile devices and the need for translation to the local language.Conclusion UTD was a feasible and acceptable clinical decision support tool for the PCPs. Factors affecting the feasibility of using UTD include technological and environmental factors (ie, internet access and the lack of translation to the local language), as well as the organisational structure of the primary care facility which determines the roles of the PCPs. Despite the difference in roles and responsibilities of the PCPs, UTD positively impacted decision-making and patient education for all PCPs through its use as a point-of-contact tool and a tool for capacity-building.

Stellar and black hole feedback heat and disperse surrounding cold gas clouds, launching gas flows off circumnuclear and galactic disks, producing a dynamic interstellar medium. On large scales bordering the cosmic web, feedback drives enriched gas out of galaxies and groups, seeding the intergalactic medium with heavy elements. In this way, feedback shapes galaxy evolution by shutting down star formation and ultimately curtailing the growth of structure after the peak at redshift 2–3. To understand the complex interplay between gravity and feedback, we must resolve both the key physics within galaxies and map the impact of these processes over large scales, out into the cosmic web. The Advanced X-ray Imaging Satellite (AXIS) is a proposed X-ray probe mission for the 2030s with arcsecond spatial resolution, large effective area, and low background. AXIS will untangle the interactions of winds, radiation, jets, and supernovae with the surrounding interstellar medium across the wide range of mass scales and large volumes driving galaxy evolution and trace the establishment of feedback back to the main event at cosmic noon. This white paper is part of a series commissioned for the AXIS Probe mission concept; additional AXIS white papers can be found at the AXIS website.

Abstract Background Inequities in health access and outcomes persist in low- and middle-income countries. While strengthening primary care is integral in improving patient outcomes, primary care networks remain undervalued, underfunded, and underdeveloped in many LMICs such as the Philippines. This paper underscores the value of strengthening primary care system interventions in LMICs by examining their impact on job satisfaction and intention to stay among healthcare workers in the Philippines. Methods This study was conducted in urban, rural, and remote settings in the Philippines. A total of 36 urban, 54 rural, and 117 remote healthcare workers participated in the study. Respondents comprised all family physicians, nurses, midwives, community health workers, and staff involved in the delivery of primary care services from the sites. A questionnaire examining job satisfaction (motivators) and dissatisfaction (hygiene) factors was distributed to healthcare workers before and after system interventions were introduced across sites. Interventions included the introduction of performance-based incentives, the adoption of electronic health records, and the enhancement of diagnostic and pharmaceutical capabilities over a 1-year period. A Wilcoxon signed-rank test and a McNemar’s chi-square test were then conducted to compare pre- and post-intervention experiences for each setting. Results Among the factors examined, results revealed a significant improvement in perceived compensation fairness among urban (p = 0.001) and rural (p = 0.016) providers. The rural workforce also reported a significant improvement in medicine access (p = 0.012) post-intervention. Job motivation and turnover intention were sustained in urban and rural settings between periods. Despite the interventions introduced, a decline in perceptions towards supply accessibility, job security, and most items classified as job motivators was reported among remote providers. Paralleling this decline, remote primary care providers with the intent to stay dropped from 93% at baseline to 75% at endline (p < 0.001). Conclusion The impact of strengthening primary care on health workforce satisfaction and turnover intention varied across urban, rural, and remote settings. While select interventions such as improving compensation were promising for better-supported settings, the immediate impact of these interventions was inadequate in offsetting the infrastructural and staffing gaps experienced in disadvantaged areas. Unless these problems are comprehensively addressed, satisfaction will remain low, workforce attrition will persist as a problem, and marginalized communities will be underserved.

We present a broadband spectral analysis of the soft-intermediate and soft states using Insight-HXMT observations of the black hole binary MAXI J1348–630 during its outburst in 2019. We employ a combination of reflection and continuum fitting methods to measure the spin of the black hole and determine a spin of a = 0.79 ± 0.13, which is consistent with most of the previous results. Additionally, we investigate some sources of systematic uncertainty that could bias the measurement. The valid spectral hardening factor can partially account for the spin evolution observed during the outburst. Other potential factors, such as assumptions about the corona’s structure and their interaction with reflected photons, can also affect the accuracy of spin measurements. Furthermore, our analysis reveals that MAXI J1348–630 exhibits a significantly high disk density (∼10 ^22 cm ^−3 ), with a moderate iron abundance of approximately 2.5 times solar.

X-ray binaries are known to launch powerful accretion disk winds that can have a significant impact on the binary systems and their surroundings. To quantify the impact and determine the launching mechanisms of these outflows, we need to measure the wind plasma number density, an important ingredient in the theoretical disk wind models. While X-ray spectroscopy is a crucial tool for understanding the wind properties, such as their velocity and ionization, in nearly all cases, we lack the signal-to-noise ratio to constrain the plasma number density, weakening the constraints on the outflow location and mass outflow rate. We present a new approach to determining this number density in the X-ray binary Hercules X-1, by measuring the speed of the wind ionization response to the time-variable illuminating continuum. Hercules X-1 is powered by a highly magnetized neutron star, pulsating with a period of 1.24 s. We show that the wind number density in Hercules X-1 is sufficiently high to respond to these pulsations by modeling the ionization response with the time-dependent photoionization model tpho . We then perform a pulse-resolved analysis of the best-quality XMM-Newton observation of Hercules X-1 and directly detect the wind response, confirming that the wind density is at least 10 ^12 cm ^−3 . Finally, we simulate XRISM observations of Hercules X-1 and show that they will allow us to accurately measure the number density at different locations within the outflow. With XRISM, we will rule out ∼3 orders of magnitude in density parameter space, constraining the wind mass outflow rate, energetics, and its launching mechanism.

We present two simultaneous NICER and NuSTAR observations of the ultracompact X-ray binary (UCXB) candidate SLX 1735−269 while the source was in two different spectral states. Using various reflection modeling techniques, we find that xillverCO , a model used for fitting X-ray spectra of UCXBs with high carbon and oxygen abundances is an improvement over relxill or relxillNS , which instead contains solar-like chemical abundances. This provides indirect evidence in support of the source being ultracompact. We also use this reflection model to get a preliminary measurement of the inclination of the system, $i={57}_{-7}^{+23}$ degrees. This is consistent with our timing analysis, where a lack of eclipses indicates an inclination of i < 80°. The timing analysis is otherwise inconclusive, and we cannot confidently measure the orbital period of the system.

The nuclear transient AT2019cuk/Tick Tock/SDSS J1430+2303 has been suggested to harbor a supermassive black hole (SMBH) binary near coalescence. We report results from high-cadence NICER X-ray monitoring with multiple visits per day from 2022 January to August, as well as continued optical monitoring during the same time period. We find no evidence of periodic/quasiperiodic modulation in the X-ray, UV, or optical bands; however, we do observe exotic hard X-ray variability that is unusual for typical active galactic nuclei (AGN). The most striking feature of the NICER light curve is repetitive hard (2–4 keV) X-ray flares that result in distinctly harder X-ray spectra compared to the nonflaring data. In its nonflaring state, AT2019cuk looks like a relatively standard AGN, but it presents the first case of day-long, hard X-ray flares in a changing-look AGN. We consider a few different models for the driving mechanism of these hard X-ray flares, including (1) corona/jet variability driven by increased magnetic activity, (2) variable obscuration, and (3) self-lensing from the potential secondary SMBH. We prefer the variable corona model, as the obscuration model requires rather contrived timescales and the self-lensing model is difficult to reconcile with a lack of clear periodicity in the flares. These findings illustrate how important high-cadence X-ray monitoring is to our understanding of the rapid variability of the X-ray corona and necessitate further high-cadence, multiwavelength monitoring of changing-look AGN like AT2019cuk to probe the corona-jet connection.

Abstract Atypical motor learning has been suggested to underpin the development of motoric challenges (e.g., handwriting difficulties) in autism. Bayesian accounts of autistic cognition propose a mechanistic explanation for differences in the learning process in autism. Specifically, that autistic individuals overweight incoming, at the expense of prior, information and are thus less likely to (a) build stable expectations of upcoming events and (b) react to statistically surprising events. Although Bayesian accounts have been suggested to explain differences in learning across a range of domains, to date, such accounts have not been extended to motor learning. 28 autistic and 35 non-autistic controls (IQ > 70) completed a computerised task in which they learned sequences of actions. On occasional “surprising” trials, an expected action had to be replaced with an unexpected action. Sequence learning was indexed as the reaction time difference between blocks which featured a predictable sequence and those that did not. Surprise-related slowing was indexed as the reaction time difference between surprising and unsurprising trials. No differences in sequence-learning or surprise-related slowing were observed between the groups. Bayesian statistics provided anecdotal to moderate evidence to support the conclusion that sequence learning and surprise-related slowing were comparable between the two groups. We conclude that individuals with autism do not show atypicalities in response to surprising events in the context of motor sequence-learning. These data demand careful consideration of the way in which Bayesian accounts of autism can (and cannot) be extended to the domain of motor learning.

Accreting supermassive black holes (SMBHs) located at the centers of galaxies are typically surrounded by large quantities of gas and dust. The structure and evolution of this circumnuclear material can be studied at different wavelengths, from the submillimeter to the X-ray. Recent X-ray studies have shown that the covering factor of the obscuring material tends to decrease with increasing Eddington ratio, likely due to radiative feedback on dusty gas. Here we study a sample of 549 nearby ( z ≲ 0.1) hard X-ray (14–195 keV) selected nonblazar active galactic nuclei (AGN) and use the ratio between the AGN infrared and bolometric luminosity as a proxy of the covering factor. We find that, in agreement with what has been found by X-ray studies of the same sample, the covering factor decreases with increasing Eddington ratio. We also confirm previous findings that showed that obscured AGN typically have larger covering factors than unobscured sources. Finally, we find that the median covering factors of AGN located in different regions of the column density–Eddington ratio diagram are in good agreement with what would be expected from a radiation-regulated growth of SMBHs.

Hercules X-1 is a nearly edge-on X-ray binary with a warped, precessing accretion disk, which manifests through a 35-day cycle of alternating High and Low flux states. This disk precession introduces a changing line of sight toward the X-ray source, through an ionized accretion disk wind. The sightline variation allows us to uniquely determine how the wind properties vary with height above the disk. All the previous wind measurements were made in the brighter Main High state of Her X-1. Here, we analyze the only Chandra observation during the fainter “Short” High state and significantly detect blueshifted ionized absorption. We find a column density of ${2.0}_{-0.6}^{+1.1}\times {10}^{22}$ cm ^−2 , an ionization parameter $\mathrm{log}(\xi $ /erg cm s ^−1 ) = ${3.41}_{-0.12}^{+0.15}$ , and an outflow velocity of 380 ± 40 km s ^−1 . The properties of the outflow measured during the Short High state are in good agreement with those measured at equivalent precession phases during the Main High state. We conclude that we are sampling the same wind structure, seen during both the Main and Short High states, which is precessing alongside the warped accretion disk every 35 days. Finally, the high spectral resolution of Chandra gratings above 1 keV in this observation enabled us to measure the abundances of certain elements in the outflow. We find Mg/O $\,=\,{1.5}_{-0.4}^{+0.5}$ , Si/O =1.5 ± 0.4, and S/O $\,=\,{3.0}_{-1.1}^{+1.2}$ , whereas in our previous study of Her X-1 with XMM-Newton, we found an overabundance of N, Ne, and Fe compared with O. These peculiar abundance ratios were likely introduced by the pollution of the donor by the supernova that created Her X-1.

We present the first joint NuSTAR and NICER observations of the ultracompact X-ray binary 4U 0614+091. This source shows quasiperiodic flux variations on the timescale of ∼days. We use reflection modeling techniques to study various components of the accretion system as the flux varies. We find that the flux of the reflected emission and the thermal components representing the disk and the compact object trend closely with the overall flux. However, the flux of the power-law component representing the illuminating X-ray corona scales in the opposite direction, increasing as the total flux decreases. During the lowest flux observation, we see evidence of accretion disk truncation from roughly 6 gravitational radii to 11.5 gravitational radii. This is potentially analogous to the truncation seen in black hole low-mass X-ray binaries, which tends to occur during the low/hard state at sufficiently low Eddington ratios.

The black hole (BH) candidate XTE J2012+381 underwent an outburst at the end of 2022. We analyzed 105 NICER observations and two NuSTAR observations of the source during the outburst. The NuSTAR observations of the M ∼ 10 M _⊙ BH indicate clear signs of relativistic disk reflection, which we modeled to measure a BH spin of $a={0.988}_{-0.030}^{+0.008}$ and an inclination of $\theta ={68}_{-11}^{+6}$ deg (1 σ statistical errors). In our analysis, we test an array of models and examine the effect of fitting NuSTAR spectra alone versus fitting simultaneously with NICER. We find that when the underlying continuum emission is properly accounted for, the reflected emission is similarly characterized by multiple models. We combined 52 NICER spectra to obtain a spectrum with an effective exposure of 190 ks in order to probe the presence of absorption lines that would be suggestive of disk winds, but the resulting features were not statistically significant. We discuss the implications of this measurement in relation to the overall BH spin distribution in X-ray binary systems.

The transient black hole X-ray binary MAXI J1803−298 was discovered on 2021 May 1, as it went into outburst from a quiescent state. As the source rose in flux it showed periodic absorption dips and fit the timing and spectral characteristics of a hard-state accreting black hole. We report on the results of a Target-of-Opportunity observation with NuSTAR obtained near the peak outburst flux beginning on 2021 May 13, after the source had transitioned into an intermediate state. MAXI J1803−298 is variable across the observation, which we investigate by extracting spectral and timing products separately for different levels of flux throughout the observation. Our timing analysis reveals two distinct potential quasiperiodic oscillations (QPOs) which are not harmonically related at 5.4 ± 0.2 Hz and 9.4 ± 0.3 Hz, present only during periods of lower flux. With clear relativistic reflection signatures detected in the source spectrum, we applied several different reflection models to the spectra of MAXI J1803−298. Here we report our results, utilizing high-density reflection models to constrain the disk geometry, and assess changes in the spectrum dependent on the source flux. With a standard broken power-law emissivity, we find a near-maximal spin for the black hole, and we are able to constrain the inclination of the accretion disk at 75° ± 2°, which is expected for a source that has shown periodic absorption dips. We also significantly detect a narrow absorption feature at 6.91 ± 0.06 keV with an equivalent width between 4 and 9 eV, which we interpret as the signature of a disk wind.

We present the results from a coordinated XMM-Newton + NuSTAR observation of the Seyfert 1 galaxy ESO 511−G030. With this joint monitoring program, we conduct a detailed variability and spectral analysis. The source remained in a low flux and very stable state throughout the observation period, although there are slight fluctuations of flux over long timescales. The broadband (0.3–78 keV) spectrum shows the presence of a power-law continuum with a soft excess below 2 keV, a relatively narrow iron K α emission (∼6.4 keV), and an obvious cutoff at high energies. We find that the soft excess can be modeled by two different possible scenarios: a warm ( kT _e ∼ 0.19 keV) and optically thick ( τ = 18–25) Comptonizing corona or a relativistic reflection from a high-density ( $\mathrm{log}[{n}_{{\rm{e}}}/{\mathrm{cm}}^{-3}]=17.1\mbox{--}18.5$ ) inner disk. All models require a low temperature ( kT _e ∼ 13 keV) for the hot corona.

We present the first results from a 100-day Swift, NICER, and ground-based X-ray–UV–optical reverberation mapping campaign of the Narrow-line Seyfert 1 Mrk 335, when it was in an unprecedented low X-ray flux state. Despite dramatic suppression of the X-ray variability, we still observe UV–optical lags as expected from disk reverberation. Moreover, the UV–optical lags are consistent with archival observations when the X-ray luminosity was >10 times higher. Interestingly, both low- and high-flux states reveal UV–optical lags that are 6–11 times longer than expected from a thin disk. These long lags are often interpreted as due to contamination from the broad line region; however the u- band excess lag (containing the Balmer jump from the diffuse continuum) is less prevalent than in other active galactic nuclei. The Swift campaign showed a low X-ray-to-optical correlation (similar to previous campaigns), but NICER and ground-based monitoring continued for another 2 weeks, during which the optical rose to the highest level of the campaign, followed ∼10 days later by a sharp rise in X-rays. While the low X-ray countrate and relatively large systematic uncertainties in the NICER background make this measurement challenging, if the optical does lead X-rays in this flare, this indicates a departure from the zeroth-order reprocessing picture. If the optical flare is due to an increase in mass accretion rate, this occurs on much shorter than the viscous timescale. Alternatively, the optical could be responding to an intrinsic rise in X-rays that is initially hidden from our line of sight.

The origin and distribution of stellar-mass black hole spins are a rare window into the progenitor stars and supernova events that create them. Swift J1728.9-3613 is an X-ray binary, likely associated with the supernova remnant (SNR) G351.9-0.9. An NuSTAR X-ray spectrum of this source during its 2019 outburst reveals reflection from an accretion disk extending to the innermost stable circular orbit. Modeling of the relativistic Doppler shifts and gravitational redshifts imprinted on the spectrum measures a dimensionless spin parameter of a = 0.86 ± 0.02 (1 σ confidence), a small inclination angle of the inner accretion disk θ < 10°, and a subsolar iron abundance in the disk A _Fe < 0.84. This high spin value rules out a neutron star primary at the 5 σ level of confidence. If the black hole is located in a still visible SNR, it must be young. Therefore, we place a lower limit on the natal black hole spin of a > 0.82, concluding that the black hole must have formed with a high spin. This demonstrates that black hole formation channels that leave an SNR, and those that do not (e.g., Cyg X-1), can both lead to high natal spin with no requirement for subsequent accretion within the binary system. Emerging disparities between the population of high-spin black holes in X-ray binaries and the low-spin black holes that merge in gravitational wave events may therefore be explained in terms of different stellar conditions prior to collapse, rather than different environmental factors after formation.