Supporting reproductive health among birthing persons with chronic conditions in the United States: A qualitative multilevel study using systems thinking to inform action.

OBJECTIVE (STUDY QUESTION): To use systems thinking with diverse system actors to (a) characterize current problems at the intersection of chronic conditions (CCs) and reproductive health (RH) care and their determinants, (b) determine necessary system actors for change, and (c) document cross-system actions that can improve identified problems in the United States. DATA SOURCES/STUDY SETTING: Data were collected from six groups of system actors via online focus groups. STUDY DESIGN: This is a qualitative multilevel study using the iceberg systems thinking framework. DATA COLLECTION/EXTRACTION METHODS: Data were collected by note-taking and recording six focus groups; analysis incorporated perspective triangulation using the systems thinking iceberg and system mapping to visualize interconnected system challenges, actors, and action ideas. PRINCIPAL FINDINGS: Participants described eight necessary system actors: health care institutions, medical leaders, medical providers, patient advocates and foundations, patients and families, payors, policy makers, and research funders. Forty pain points were identified, spread across each of the four levels of the systems thinking iceberg: undesirable outcomes (6), concerning trends (9), system structure flaws (15), and problematic mental models (10). In response to these pain points, a set of 46 action ideas was generated by participants and mapped into nine action themes: (1) adjust QI metrics, incentives, and reimbursement, (2) bolster RH medical education and training, (3) break down medical silos, (4) enrich patient education, (5) expand the health care team, (6) improve holistic health care, (7) modify research and programmatic funding to prioritize RH and CC, (8) spur innovation for patient visits, and (9) support professional champions and leaders. CONCLUSIONS: By embracing system complexity, creating visual maps, and pushing participants to identify actionable strategies for improvement, this study generates a set of specific actions that can be used to address pain points across the multiple system levels that make improving reproductive care for people with CCs so challenging.

Enhancing Title V Workforce Capacity to Address Complex Challenges: Impact of the National Maternal and Child Health Workforce Development Center.

INTRODUCTION: The National Maternal and Child Health Workforce Development Center provides training, coaching, and consultation to Title V programs. The flagship experience is the Cohort program, a 6-8-month leadership development program where Title V programs convene a multisector team to address a pre-selected state/jurisdictional challenge related to health systems transformation. The overall objective of this paper is to demonstrate the impact of skills developed via the Cohort program on state/jurisdictional capacities to address complex challenges. METHODS: Qualitative, post-Cohort evaluation data were analyzed using inductive and deductive coding and the "Sort and Sift, Think and Shift" method. Themes and supporting text were summarized using episode profiles for each team and subsequently organized using the EvaluLEAD methodology for identifying and documenting impact. RESULTS: Teams brought an array of challenges related to health systems transformation and 94% of teams reported achieving progress on their challenge six-months after the Cohort program. Teams described how the Cohort program improved workforce skills in strategic thinking, systems thinking, adaptive leadership, and communication. Teams also reported the Cohort program contributed to stronger partnerships, improved sustainability of their project, produced mindset shifts, and increased confidence. The Cohort program has also led to improved population health outcomes. DISCUSSION: Through working with the Center, Title V leaders and their teams achieved episodic, developmental, and transformative results through application of Center tools and skills to complex challenges. Investment in the MCH workforce through skill development is critical for achieving transformative results and solving "wicked" public health problems.

Developing State Leadership in Maternal and Child Health: Process Evaluation Findings from a Work-Based Learning Model for Leadership Development.

OBJECTIVES: Since 2013 the MCH Bureau has supported the National MCH Workforce Development Center to strengthen the Title V MCH workforce. This article describes the Center's Cohort Program and lessons learned about work-based learning, instruction, and coaching. DESCRIPTION: The Cohort Program is a leadership development program that enrolls state-level teams for skill development and work-based learning to address a self-identified challenge in their state. Teams attend a Learning Institute that teaches concepts, skills, and practical tools in systems integration; change management and adaptive leadership; and evidence-based decision-making and implementation. Teams then work back home on their challenges, aided by coaching. The Program's goals are for teams to expand and use their skills to address their challenge, and that teams would strengthen programs, organizations, and policies, use their skills to address other challenges, and ultimately improve MCH outcomes. METHODS: This process evaluation is based on evaluation forms completed by attendees at the three-day Learning Institute; six-month follow-up interviews with team leaders; and a modified focus group with staff. RESULTS: Participants and staff believe the Cohort Program effectively merges a practical skill-based curriculum, work-based learning in teams, and coaching. The Learning Institute provides a foundation of skills and tools, strengthens the team's relationship with their coach, and builds the team. The work-based learning period provides structure, accountability, and a "practice space" for teams to apply the Cohort Program's skills and tools to address their challenge. In this period, teams deepen collaborations and often add partners. The coach provides accessible and tailored guidance in teamwork and skill application. These dimensions helped teams in develop skills and address state-level MCH challenges. CONCLUSIONS FOR PRACTICE: Continuing professional development programs can help leaders learn to address complex state-level MCH challenges through integrated classroom-based skills development, work-based learning on state challenges, and tailored coaching.

Description of two new species of Prodontorhabditis Timm, 1961 (Nematoda: Rhabditidae) from India.

Two new species, Prodontorhabditis robustus sp. n. and P. grandistoma sp. n. are described and illustrated from rotting banana rhizome and decaying organic matter respectively. P. robustus sp. n. is characterized by thin and slender females with L= 490-625 µm; a= 25.8-34.7; b= 4.9-6.4; c= 2.4-3.7, an arched cheilostom with curved walls bearing basal dorsal and subventral denticles at the same level, males with 20-23 µm long, robust spicules with prominent dorsal velum and lateral spurs at its bifurcated distal tip and gubernaculum with attenuated proximal end. P. grandistoma sp. n. is characterized by plump females with L= 440-552 µm; a= 23.9-25.5; b= 4.4-5.7; c= 2.9-4.2, a long, narrow stoma of length 6-7 times diameter; the cheilostom straight but, wider anteriorly with a basal dorsal denticle and anterior subventral denticles, rectum with dilated lumen, males with 17-20 µm long, relatively slender spicules and a terminally indented bursa. This is the first report of Prodontorhabditis species from India. An updated list of species, a key to their identification and a compendium of their morphometrics and diagnostic features is presented.

Bioenergetic theory predicts infection dynamics of human schistosomes in intermediate host snails across ecological gradients.

Epidemiological dynamics depend on the traits of hosts and parasites, but hosts and parasites are heterogeneous entities that exist in dynamic environments. Resource availability is a particularly dynamic and potent environmental driver of within-host infection dynamics (temporal patterns of growth, reproduction, parasite production and survival). We developed, parameterised and validated a model for resource-explicit infection dynamics by incorporating a parasitism module into dynamic energy budget theory. The model mechanistically explained the dynamic multivariate responses of the human parasite Schistosoma mansoni and its intermediate host snail to variation in resources and host density. At the population level, feedbacks mediated by resource competition could create a unimodal relationship between snail density and human risk of exposure to schistosomes. Consequently, weak snail control could backfire if reductions in snail density release remaining hosts from resource competition. If resource competition is strong and relevant to schistosome production in nature, it could inform control strategies.

Considerations for sustainable influenza vaccine production in developing countries.

Through its Global Action Plan for Influenza Vaccines (GAP), the World Health Organization (WHO) in collaboration with the United States Department of Health and Human Services has produced a checklist to support policy-makers and influenza vaccine manufacturers in identifying key technological, political, financial, and logistical issues affecting the sustainability of influenza vaccine production. This checklist highlights actions in five key areas that are beneficial for establishing successful local vaccine manufacturing. These five areas comprise: (1) the policy environment and health-care systems; (2) surveillance systems and influenza evidence; (3) product development and manufacturing; (4) product approval and regulation; and (5) communication to support influenza vaccination. Incorporating the checklist into national vaccine production programmes has identified the policy gaps and next steps for countries involved in GAP's Technology Transfer Initiative. Lessons learnt from country experiences provide context and insight that complement the checklist's goal of simplifying the complexities of influenza prevention, preparedness, and vaccine manufacturing.

Stakeholders' perceptions of 10years of the Global Action Plan for Influenza Vaccines (GAP) - Results from a survey.

Ten years after the launch of the Global Action Plan for Influenza Vaccines (GAP), the World Health Organization (WHO) surveyed stakeholders to understand their perceptions of what the programme had achieved. This article provides a summary of the findings; the full report will be available on-line on the GAP website in November 2016 (http://www.who.int/influenza_vaccines_plan/en/). Seventy-seven responses were received from stakeholders including medical doctors, national influenza center officials, country immunization programme teams, surveillance and disease centers, policy-makers, researchers, vaccine manufacturers, and non-governmental organizations from 28 countries, representing all six WHO regions. Respondents cited GAP's biggest successes as capacity building in developing countries; raising international awareness of global needs in the event of a pandemic; and collaborative alignment of influenza stakeholders. The most commonly reported challenges were the limited progress in development of a broadly protective or universal vaccine and the perceived absence of a major increase in seasonal demand. These findings aligned with the perception that less global progress had been made under the third GAP objective, focused on research and development of better vaccines, than on increasing seasonal vaccine use (objective 1) and pandemic vaccine production capacity (objective 2). Respondents explained what they saw as the major challenges to development of better vaccines, including to development of a universal influenza vaccine. The majority of respondents agreed that the goal chosen at the GAP II consultation is still relevant. Results highlighted the importance of promoting research and development of better vaccines, both for facilitating uptake of seasonal vaccines and for ensuring timely vaccine availability in the event of a pandemic. As the GAP concludes its mandate this year, these findings will contribute to discussions on the impact of programme closure and how to address the key issues facing influenza stakeholders thereafter.

A decade of adaptation: Regulatory contributions of the World Health Organization to the Global Action Plan for Influenza Vaccines (2006-2016).

The Global Action Plan (GAP) for Influenza Vaccines is a decade-long initiative that brings together a diverse range of stakeholders to work towards reducing anticipated global shortage of influenza vaccines and ensuring more equitable access to vaccines during the next influenza pandemic. Since its inception in 2006, significant progress has been made towards all the main objectives of GAP, namely: (1) an increase in seasonal vaccine use, (2) an increase in vaccine production, and (3) progress in research and development of more effective vaccines. The Technology Transfer Initiative (TTI), conceived and managed by WHO under the GAP, contributed to increasing regional influenza vaccine production capacity. This was achieved by facilitating technology transfer in 14 low- and middle-income countries, through grants to manufacturers to establish or strengthen influenza vaccine production capacity and support to their national regulatory authorities. Five of the countries subsequently licensed locally produced influenza vaccines; two pandemic and three seasonal vaccines received WHO prequalification. The success of GAP can be largely attributed to the regulatory support provided by WHO to both manufacturers and regulators. This support had two components: (1) direct regulatory support to GAP/TTI, and (2) support to GAP-related WHO programmes, such as the Pandemic Influenza Vaccine Deployment Initiative in 2010 and the Pandemic Influenza Preparedness Framework since 2013, especially in non-vaccine-producing countries. Temporary adaptation of the assessment process for influenza vaccines in the WHO Vaccine Prequalification Programme to the A(H1N1) pandemic situation in 2009 was instrumental to the success of the WHO Pandemic Influenza Vaccine Deployment Initiative in its attempt to meet the demand for pandemic vaccines in countries that received donated vaccines.

Biodiversity inhibits parasites: Broad evidence for the dilution effect.

Infectious diseases of humans, wildlife, and domesticated species are increasing worldwide, driving the need to understand the mechanisms that shape outbreaks. Simultaneously, human activities are drastically reducing biodiversity. These concurrent patterns have prompted repeated suggestions that biodiversity and disease are linked. For example, the dilution effect hypothesis posits that these patterns are causally related; diverse host communities inhibit the spread of parasites via several mechanisms, such as by regulating populations of susceptible hosts or interfering with parasite transmission. However, the generality of the dilution effect hypothesis remains controversial, especially for zoonotic diseases of humans. Here we provide broad evidence that host diversity inhibits parasite abundance using a meta-analysis of 202 effect sizes on 61 parasite species. The magnitude of these effects was independent of host density, study design, and type and specialization of parasites, indicating that dilution was robust across all ecological contexts examined. However, the magnitude of dilution was more closely related to the frequency, rather than density, of focal host species. Importantly, observational studies overwhelmingly documented dilution effects, and there was also significant evidence for dilution effects of zoonotic parasites of humans. Thus, dilution effects occur commonly in nature, and they may modulate human disease risk. A second analysis identified similar effects of diversity in plant-herbivore systems. Thus, although there can be exceptions, our results indicate that biodiversity generally decreases parasitism and herbivory. Consequently, anthropogenic declines in biodiversity could increase human and wildlife diseases and decrease crop and forest production.