The state of costing research for HIV interventions in sub-Saharan Africa.

The past decade has seen a growing emphasis on the production of high-quality costing data to improve the efficiency and cost-effectiveness of global health interventions. The need for such data is especially important for decision making and priority setting across HIV services from prevention and testing to treatment and care. To help address this critical need, the Global Health Cost Consortium was created in 2016, in part to conduct a systematic search and screening of the costing literature for HIV and TB interventions in low- and middle-income countries (LMIC). The purpose of this portion of the remit was to compile, standardise, and make publicly available published cost data (peer-reviewed and gray) for public use. We limit our analysis to a review of the quantity and characteristics of published cost data from HIV interventions in sub-Saharan Africa. First, we document the production of cost data over 25 years, including density over time, geography, publication venue, authorship and type of intervention. Second, we explore key methods and reporting for characteristics including urbanicity, platform type, ownership and scale. Although the volume of HIV costing data has increased substantially on the continent, cost reporting is lacking across several dimensions. We find a dearth of cost estimates from HIV interventions in west Africa, as well as inconsistent reporting of key dimensions of cost including platform type, ownership and urbanicity. Further, we find clear evidence of a need for renewed focus on the consistent reporting of scale by authors of costing and cost-effectiveness analyses.

Developing the Global Health Cost Consortium Unit Cost Study Repository for HIV and TB: methodology and lessons learned.

Consistently defined, accurate, and easily accessible cost data are a valuable resource to inform efficiency analyses, budget preparation, and sustainability planning in global health. The Global Health Cost Consortium (GHCC) designed the Unit Cost Study Repository (UCSR) to be a resource for standardised HIV and TB intervention cost data displayed by key characteristics such as intervention type, country, and target population. To develop the UCSR, the GHCC defined a typology of interventions for each disease; aligned interventions according to the standardised principles, methods, and cost and activity categories from the GHCC Reference Case for Estimating the Costs of Global Health Services and Interventions; completed a systematic literature review; conducted extensive data extraction; performed quality assurance; grappled with complex methodological issues such as the proper approach to the inflation and conversion of costs; developed and implemented a study quality rating system; and designed a web-based user interface that flexibly displays large amounts of data in a user-friendly way. Key lessons learned from the extraction process include the importance of assessing the multiple uses of extracted data; the critical role of standardising definitions (particularly units of measurement); using appropriate classifications of interventions and components of costs; the efficiency derived from programming data checks; and the necessity of extraction quality monitoring by senior analysts. For the web interface, lessons were: understanding the target audiences, including consulting them regarding critical characteristics; designing the display of data in "levels"; and incorporating alert and unique trait descriptions to further clarify differences in the data.

Parents as Teachers Health Literacy Demonstration project: integrating an empowerment model of health literacy promotion into home-based parent education.

The Parents as Teachers (PAT) Health Literacy Demonstration project assessed the impact of integrating data-driven reflective practices into the PAT home visitation model to promote maternal health literacy. PAT is a federally approved Maternal, Infant, Early Childhood Home Visiting program with the goal of promoting school readiness and healthy child development. This 2-year demonstration project used an open-cohort longitudinal design to promote parents' interactive and reflective skills, enhance health education, and provide direct assistance to personalize and act on information by integrating an empowerment paradigm into PAT's parent education model. Eight parent educators used the Life Skills Progression instrument to tailor the intervention to each of 103 parent-child dyads. Repeated-measures analysis of variance, paired t tests, and logistic regression combined with qualitative data demonstrated that mothers achieved overall significant improvements in health literacy, and that home visitors are important catalysts for these improvements. These findings support the use of an empowerment model of health education, skill building, and direct information support to enable parents to better manage personal and child health and health care.

Visualization and analytics tools for infectious disease epidemiology: a systematic review.

BACKGROUND: A myriad of new tools and algorithms have been developed to help public health professionals analyze and visualize the complex data used in infectious disease control. To better understand approaches to meet these users' information needs, we conducted a systematic literature review focused on the landscape of infectious disease visualization tools for public health professionals, with a special emphasis on geographic information systems (GIS), molecular epidemiology, and social network analysis. The objectives of this review are to: (1) identify public health user needs and preferences for infectious disease information visualization tools; (2) identify existing infectious disease information visualization tools and characterize their architecture and features; (3) identify commonalities among approaches applied to different data types; and (4) describe tool usability evaluation efforts and barriers to the adoption of such tools. METHODS: We identified articles published in English from January 1, 1980 to June 30, 2013 from five bibliographic databases. Articles with a primary focus on infectious disease visualization tools, needs of public health users, or usability of information visualizations were included in the review. RESULTS: A total of 88 articles met our inclusion criteria. Users were found to have diverse needs, preferences and uses for infectious disease visualization tools, and the existing tools are correspondingly diverse. The architecture of the tools was inconsistently described, and few tools in the review discussed the incorporation of usability studies or plans for dissemination. Many studies identified concerns regarding data sharing, confidentiality and quality. Existing tools offer a range of features and functions that allow users to explore, analyze, and visualize their data, but the tools are often for siloed applications. Commonly cited barriers to widespread adoption included lack of organizational support, access issues, and misconceptions about tool use. DISCUSSION AND CONCLUSION: As the volume and complexity of infectious disease data increases, public health professionals must synthesize highly disparate data to facilitate communication with the public and inform decisions regarding measures to protect the public's health. Our review identified several themes: consideration of users' needs, preferences, and computer literacy; integration of tools into routine workflow; complications associated with understanding and use of visualizations; and the role of user trust and organizational support in the adoption of these tools. Interoperability also emerged as a prominent theme, highlighting challenges associated with the increasingly collaborative and interdisciplinary nature of infectious disease control and prevention. Future work should address methods for representing uncertainty and missing data to avoid misleading users as well as strategies to minimize cognitive overload.

Distinct anal microbiome is correlated with anal cancer precursors in MSM with HIV.

OBJECTIVES: Anal cancer risk is elevated in MSM with HIV (MSMWH). Anal high-risk human papillomavirus (hr-HPV) infection is necessary but insufficient to develop high-grade squamous intraepithelial lesion (HSIL), the anal cancer precursor, suggesting additional factors. We sought to determine whether the microbiome of the anal canal is distinct by comparing it with the microbiome of stool. We also sought to determine whether changes in the anal microbiome are associated with HSIL among MSMWH. DESIGN: Cross-sectional comparison of the microbiome of the anal canal with the microbiome of stool in MSMWH and cross-sectional comparison of the anal microbiome of MSMWH with anal HSIL with the anal microbiome of MSMWH without anal HSIL. METHODS: Sterile swabs were used to sample the anus of MSMWH for microbiome and HPV testing, followed by high-resolution anoscopy. Stool samples were mailed from home. 16S sequencing was used for bacterial identification. Measures of alpha diversity, beta diversity, and differential abundance analysis were used to compare samples. RESULTS: One hundred sixty-six anal samples and 103 matching stool samples were sequenced. Beta diversity showed clustering of stool and anal samples. Of hr-HPV-positive MSMWH, 31 had HSIL and 13 had no SIL. Comparison of the microbiome between these revealed 28 different species. The highest-fold enrichment among MSMWH/hr-HPV/HSIL included pro-inflammatory and carcinogenic Prevotella, Parasuterella, Hungatella, Sneathia, and Fusobacterium species. The anti-inflammatory Anaerostipes caccae showed the greatest reduction among MSMWH/hr-HPV/HSIL. CONCLUSION: The anal microbiome is distinct from stool. A pro-inflammatory and carcinogenic environment may be associated with anal HSIL.

Serving limited English proficient callers: a survey of 9-1-1 police telecommunicators.

INTRODUCTION: The emergency telephone number 9-1-1 serves as a lifeline to the public during emergencies, and first responders rely on information gathered by 9-1-1 telecommunicators who speak with callers. Timely, accurate information from the telecommunicators is essential for providing appropriate care on scene. Language barriers can hamper these efforts and result in less efficient information exchange. Although 9-1-1 telecommunicators may access over-the-phone interpreter (OPI) services to facilitate communication, managing three-way communication during an emergency is challenging. Problem There is little published on the relationship between limited English proficient (LEP) callers and 9-1-1 police telecommunicators, and the role of OPI services during these calls. Further, little is known about effective strategies to manage such calls. METHODS: In King County, Washington, 9-1-1 police telecommunicators were surveyed about their experiences handling LEP calls and managing three-way communication with OPI services. The survey contained 13 multiple-choice and three open-response questions addressing communication strategies, challenges with LEP callers, and three-way communication with OPI services. Goodman-Kruskal Gamma and chi-square tests were conducted with OPI use as the dependent variable. Additional analyses were conducted using stress levels as the dependent variable. RESULTS: Of 123 respondents, 69 (56.5%) 9-1-1 telecommunicators reported utilizing OPI services at least 75% of the time when receiving a call from an LEP caller. Further, 35 (28.7%) of these telecommunicators reported calls with LEP individuals as more stressful than calls with fluent English speakers. Dispatcher stress level during LEP calls compared with stress during calls with fluent English speakers was positively associated with use of OPI services (P < .01). Further, stress level was also positively associated with telecommunicator difficulties in assessing the situation with respect to officer safety (P < .01). Sixty-three (58.3%) of the telecommunicators described difficulties assessing the situation to determine the appropriate response as the biggest challenge with LEP callers. Additionally, 62 (53%) identified knowing their location in English as information LEP callers need to know prior to calling 9-1-1. CONCLUSION: These results highlight intervention opportunities for both 9-1-1 telecommunicators and LEP communities. Together, interventions such as working with LEP communities to educate them on best communication practices during 9-1-1 calls, and with 9-1-1 telecommunicators to help them manage three-way communication and reduce stress associated with concern for officer safety may improve emergency communication during 9-1-1 calls.

Differential impact of test performance characteristics on burden-to-benefit tradeoffs for blood-based colorectal cancer screening: A microsimulation analysis.

OBJECTIVES: To inform the development and evaluation of new blood-based colorectal cancer (CRC) screening tests satisfying minimum United States (US) coverage criteria, we estimated the impact of the different test performance characteristics on long-term testing benefits and burdens. METHODS: A novel CRC-Microsimulation of Adenoma Progression and Screening (CRC-MAPS) model was developed, validated, then used to assess different screening tests for CRC. We compared multiple, hypothetical blood-based CRC screening tests satisfying minimum coverage criteria of 74% CRC sensitivity and 90% specificity, to measure how changes in a test's CRC sensitivity, specificity, and adenoma sensitivity (sizes 1-5 mm, 6-9 mm, ≥10 mm) affect total number of colonoscopies (COL), CRC incidence reduction (IR), CRC mortality reduction (MR), and burden-to-benefit ratios (incremental COLs per percentage-point increase in IR or MR). RESULTS: A blood test meeting minimum US coverage criteria for performance characteristics resulted in 1576 lifetime COLs per 1000 individuals, 46.7% IR and 59.2% MR compared to no screening. Tests with increased CRC sensitivity of 99% ( + 25%) vs. increased ≥10 mm adenoma sensitivity of 13.6% ( + 3.6%) both yielded the same MR, 62.7%. Test benefits improved the most with increases in all-size adenoma sensitivity, then size-specific adenoma sensitivities, then specificity and CRC sensitivity, while increases in specificity or ≥10 mm adenoma sensitivity resulted in the most favorable burden-to-benefit tradeoffs (ratios <11.5). CONCLUSIONS: Burden-to-benefit ratios for blood-based CRC screening tests differ by performance characteristic, with the most favorable tradeoffs resulting from improvements in specificity and ≥10 mm adenoma sensitivity.

Gut microbiome composition and risk factors in a large cross-sectional IBS cohort.

Objective: Irritable bowel syndrome (IBS) is a common gastrointestinal disorder that is difficult to diagnose and treat due to its inherent heterogeneity and unclear aetiology. Although there is evidence suggesting the importance of the microbiome in IBS, this association remains poorly defined. In the current study, we aimed to characterise a large cross-sectional cohort of patients with self-reported IBS in terms of microbiome composition, demographics, and risk factors. Design: Individuals who had previously submitted a stool sample for 16S microbiome sequencing were sent a comprehensive survey regarding IBS diagnosis, demographics, health history, comorbidities, family history, and symptoms. Log ratio-transformed abundances of microbial taxa were compared between individuals reporting a diagnosis of IBS without any comorbidities and individuals reporting no health conditions. Univariable testing was followed by a multivariable logistic regression model controlling for relevant confounders. Results: Out of 6386 respondents, 1692 reported a diagnosis of IBS without comorbidities and 1124 reported no health conditions. We identified 3 phyla, 15 genera, and 19 species as significantly associated with IBS after adjustment for confounding factors. Demographic risk factors include a family history of gut disorders and reported use of antibiotics in the last year. Conclusion: The results of this study confirm important IBS risk factors in a large cohort and support a connection for microbiome compositional changes in IBS pathogenesis. The results also suggest clinical relevance in monitoring and investigating the microbiome in patients with IBS. Further, the exploratory models described here provide a foundation for future studies.

Data-Driven Maternal Health Literacy Promotion and a Postscript on Its Implications.

Scientific discovery and global health policy are moving health literacy promotion and maternal-child health from the fringes of research and public health to the forefront of healthcare reform [1]. In 2011 the United Nations General Assembly adopted the Shanghai Declaration [2]. The Declaration highlights new understanding of the origins of health and disease in early development. It calls on all nations to apply this knowledge to reduce the burdens of chronic disease and related disparities worldwide. The Declaration recommends a specific intervention strategy: promote health literacy across the life course, particularly in parents and children, and empower women. This chapter explores findings and implications of the Life Skills Progression Maternal Health Literacy studies. These LSP-MHL studies evaluated implementations of an intervention designed to promote health literacy in parents and empower women in the U.S. First, the chapter reports findings of the most recent of five published LSP-MHL studies with discussion of its implications for future work in this line of inquiry. A postscript highlights two of many implications of the LSP-MHL intervention studies for health literacy research in the third era of modern healthcare.