Implementing value-based healthcare using a digital health exchange platform to improve pregnancy and childbirth outcomes in urban and rural Kenya.

Maternal and neonatal mortality rates in many low- and middle-income countries (LMICs) are still far above the targets of the United Nations Sustainable Development Goal 3. Value-based healthcare (VBHC) has the potential to outperform traditional supply-driven approaches in changing this dismal situation, and significantly improve maternal, neonatal and child health (MNCH) outcomes. We developed a theory of change and used a cohort-based implementation approach to create short and long learning cycles along which different components of the VBHC framework were introduced and evaluated in Kenya. At the core of the approach was a value-based care bundle for maternity care, with predefined cost and quality of care using WHO guidelines and adjusted to the risk profile of the pregnancy. The care bundle was implemented using a digital exchange platform that connects pregnant women, clinics and payers. The platform manages financial transactions, enables bi-directional communication with pregnant women via SMS, collects data from clinics and shares enriched information via dashboards with payers and clinics. While the evaluation of health outcomes is ongoing, first results show improved adherence to evidence-based care pathways at a predictable cost per enrolled person. This community case study shows that implementation of the VBHC framework in an LMIC setting is possible for MNCH. The incremental, cohort-based approach enabled iterative learning processes. This can support the restructuring of health systems in low resource settings from an output-driven model to a value based financing-driven model.

What prevents pregnant women from adhering to the continuum of maternal care? Evidence on interrelated mechanisms from a cohort study in Kenya.

OBJECTIVES: To examine the determinants of the continuum of maternal care from an integrated perspective, focusing on how key components of an adequate journey are interrelated. DESIGN: A facility-based prospective cohort study. SETTING: 25 health facilities across three counties of Kenya: Nairobi, Kisumu and Kakamega. PARTICIPANTS: A total of 5 879 low-income pregnant women aged 13-49 years. OUTCOME MEASURES: Ordinary least squares, Poisson and logistic regression models were employed, to predict three key determinants of the continuum of maternal care: (i) the week of enrolment at the clinic for antenatal care (ANC), (ii) the total number of ANC visits and (iii) utilisation of skilled birth attendance (SBA). The interrelationship between the three outcome variables was assessed with structural equation modeling. RESULTS: Each week of delayed enrolment in ANC reduced the number of ANC visits by 3% (incidence rate ratio=0.967, 95% CI 0.965 to 0.969). A higher number of ANC visits increased the relative probability of using SBA (odds ratio=1.28, 95% CI 1.22 to 1.34). The direct association between late enrolment and SBA was positive (odds ratio=1.033, 95% CI 1.02 to 1.04). Predisposing factors (age, household head's education), enabling factors (wealth, shorter distance, rural area) and need factors (risk level of pregnancy, multigravida) were positively associated with adherence to ANC. CONCLUSION: The results point towards a domino-effect and underscore the importance of enhancing the full continuum of maternal care. A larger number of ANC visits increases SBA, while early initiation of the care journey increases the number of ANC visits, thereby indirectly supporting SBA as well. These beneficial pathways counteract the direct link between enrolment and SBA, which is partly driven by pregnant teenagers who both enrol late and are at heightened risk of complications, stressing the need for specific attention to this vulnerable population.

Digital health systems strengthening in Africa for rapid response to COVID-19.

The COVID-19 pandemic has painfully exposed the constraints of fragile health systems in low- and middle-income countries, where global containment measures largely set by high-income countries resulted in disproportionate collateral damage. In Africa, a shift is urgently needed from emergency response to structural health systems strengthening efforts, which requires coordinated interventions to increase access, efficiency, quality, transparency, equity, and flexibility of health services. We postulate that rapid digitalization of health interventions is a key way forward to increase resilience of African health systems to epidemic challenges. In this paper we describe how PharmAccess' ongoing digital health system interventions in Africa were rapidly customized to respond to COVID-19. We describe how we developed: a COVID-19 App for healthcare providers used by more than 1,000 healthcare facilities in 15 African countries from May-November 2020; digital loans to support private healthcare providers with USD 20 million disbursed to healthcare facilities impacted by COVID-19 in Kenya; a customized Dutch mobile COVID-19 triage App with 4,500 users in Ghana; digital diaries to track COVID-19 impacts on household expenditures and healthcare utilization; a public-private partnership for real-time assessment of COVID-19 diagnostics in West-Kenya; and an expanded mobile phone-based maternal and child-care bundle to include COVID-19 adapted services. We also discuss the challenges we faced, the lessons learned, the impact of these interventions on the local healthcare system, and the implications of our findings for policy-making. Digital interventions bring efficiency due to their flexibility and timeliness, allowing co-creation, targeting, and rapid policy decisions through bottom-up approaches. COVID-19 digital innovations allowed for cross-pollinating the interests of patients, providers, payers, and policy-makers in challenging times, showing how such approaches can pave the way to universal health coverage and resilient healthcare systems in Africa.

Public-private partnership to rapidly strengthen and scale COVID-19 response in Western Kenya.

Introduction: In Africa almost half of healthcare services are delivered through private sector providers. These are often underused in national public health responses. To support and accelerate the public sector's COVID-19 response, we facilitated recruitment of additional private sector capacity by initiating a public-private partnership (PPP) in Kisumu County, Kenya. In this manuscript we demonstrate this PPP's performance. Methods: COVID-19 diagnostic testing formed the basis for a PPP between Kenyan Medical Research Institute (KEMRI), Department of Health Kisumu County, PharmAccess Foundation, and local faith-based and private healthcare facilities: COVID-Dx. First phase COVID-Dx was implemented from June 01, 2020, to March 31, 2021 in Kisumu County, Kenya. Trained laboratory technologists in participating healthcare facilities collected nasopharyngeal and oropharyngeal samples from patients meeting the Kenyan MoH COVID-19 case definition. Healthcare workers in participating facilities collected patient clinical data using a digitized MoH COVID-19 Case Identification Form. We shared aggregated results from these data via (semi-) live dashboards with all relevant stakeholders through their mobile phones and tablets. Statistical analyses were performed using Stata 16 to inform project processes. Results: Nine private facilities participated in the project. A patient trajectory was developed from case identification to result reporting, all steps supported by a semi-real time digital dashboard. A total of 4,324 PCR tests for SARS-CoV-2 were added to the public response, identifying 425 positives, accounting for 16% of all COVID-19 tests performed in the County over the given time-period. Geo-mapped and time-tagged information on incident cases was depicted on Google maps through PowerBI-dashboards and fed back to policymakers for informed rapid decision making. Preferential COVID-19 testing was performed on health workers at risk, with 1,009 tests performed (up to 43% of all County health workforce). Conclusion: We demonstrate feasibility of rapidly increasing the public health sector COVID-19 response through coordinated private sector efforts in an African setting. Our PPP intervention in Kisumu, Kenya was based on a joint testing strategy and demonstrated that semi-real time digitalization of patient trajectories can gain significant efficiencies, linking public and private healthcare efforts, increasing transparency, support better quality health services and informing policy makers to target interventions.

Does higher sampling rate (multiband + SENSE) improve group statistics - An example from social neuroscience block design at 3T.

Multiband (MB) or Simultaneous multi-slice (SMS) acquisition schemes allow the acquisition of MRI signals from more than one spatial coordinate at a time. Commercial availability has brought this technique within the reach of many neuroscientists and psychologists. Most early evaluation of the performance of MB acquisition employed resting state fMRI or the most basic tasks. In this study, we tested whether the advantages of using MB acquisition schemes generalize to group analyses using a cognitive task more representative of typical cognitive neuroscience applications. Twenty-three subjects were scanned on a Philips 3 â€‹T scanner using five sequences, up to eight-fold acceleration with MB-factors 1 to 4, SENSE factors up to 2 and corresponding TRs of 2.45s down to 0.63s, while they viewed (i) movie blocks showing complex actions with hand object interactions and (ii) control movie blocks without hand object interaction. Data were processed using a widely used analysis pipeline implemented in SPM12 including the unified segmentation and canonical HRF modelling. Using random effects group-level, voxel-wise analysis we found that all sequences were able to detect the basic action observation network known to be recruited by our task. The highest t-values were found for sequences with MB4 acceleration. For the MB1 sequence, a 50% bigger voxel volume was needed to reach comparable t-statistics. The group-level t-values for resting state networks (RSNs) were also highest for MB4 sequences. Here the MB1 sequence with larger voxel size did not perform comparable to the MB4 sequence. Altogether, we can thus recommend the use of MB4 (and SENSE 1.5 or 2) on a Philips scanner when aiming to perform group-level analyses using cognitive block design fMRI tasks and voxel sizes in the range of cortical thickness (e.g. 2.7 â€‹mm isotropic). While results will not be dramatically changed by the use of multiband, our results suggest that MB will bring a moderate but significant benefit.

An investigation of the neural circuits underlying reaching and reach-to-grasp movements: from planning to execution.

Experimental evidence suggests the existence of a sophisticated brain circuit specifically dedicated to reach-to-grasp planning and execution, both in human and non-human primates (Castiello, 2005). Studies accomplished by means of neuroimaging techniques suggest the hypothesis of a dichotomy between a "reach-to-grasp" circuit, involving the anterior intraparietal area, the dorsal and ventral premotor cortices (PMd and PMv - Castiello and Begliomini, 2008; Filimon, 2010) and a "reaching" circuit involving the medial intraparietal area and the superior parieto-occipital cortex (Culham et al., 2006). However, the time course characterizing the involvement of these regions during the planning and execution of these two types of movements has yet to be delineated. A functional magnetic resonance imaging study has been conducted, including reach-to-grasp and reaching only movements, performed toward either a small or a large stimulus, and Finite Impulse Response model (Henson, 2003) was adopted to monitor activation patterns from stimulus onset for a time window of 10 s duration. Data analysis focused on brain regions belonging either to the reaching or to the grasping network, as suggested by Castiello and Begliomini (2008). Results suggest that reaching and grasping movements planning and execution might share a common brain network, providing further confirmation to the idea that the neural underpinnings of reaching and grasping may overlap in both spatial and temporal terms (Verhagen et al., 2013). But, although responsive for both actions, they show a significant predominance for either one of the two actions and such a preference is evident on a temporal scale.

Object size modulates fronto-parietal activity during reaching movements.

In both monkeys and humans, reaching-related sensorimotor transformations involve the activation of a wide fronto-parietal network. Recent neurophysiological evidence suggests that some components of this network host not only neurons encoding the direction of arm reaching movements, but also neurons whose involvement is modulated by the intrinsic features of an object (e.g. size and shape). To date, it has yet to be investigated whether a similar modulation is evident in the human reaching-related areas. To fill this gap, we asked participants to reach towards either a small or a large object while kinematic and electroencephalographic signals were recorded. Behavioral results showed that the precision requirements were taken into account and the kinematics of reaching was modulated depending on the object size. Similarly, reaching-related neural activity at the level of the posterior parietal and premotor cortices was modulated by the level of accuracy determined by object size. We therefore conclude that object size is engaged in the neural computations for reach planning and execution, consistent with the results from physiological studies in non-human primates.

Co-registering kinematics and evoked related potentials during visually guided reach-to-grasp movements.

BACKGROUND: In non-human primates grasp-related sensorimotor transformations are accomplished in a circuit involving the anterior intraparietal sulcus (area AIP) and both the ventral and the dorsal sectors of the premotor cortex (vPMC and dPMC, respectively). Although a human homologue of such a circuit has been identified, the time course of activation of these cortical areas and how such activity relates to specific kinematic events has yet to be investigated. METHODOLOGY/PRINCIPAL FINDINGS: We combined kinematic and event-related potential techniques to explicitly test how activity within human grasping-related brain areas is modulated in time. Subjects were requested to reach towards and grasp either a small stimulus using a precision grip (i.e., the opposition of index finger and thumb) or a large stimulus using a whole hand grasp (i.e., the flexion of all digits around the stimulus). Results revealed a time course of activation starting at the level of parietal regions and continuing at the level of premotor regions. More specifically, we show that activity within these regions was tuned for specific grasps well before movement onset and this early tuning was carried over--as evidenced by kinematic analysis--during the preshaping period of the task. CONCLUSIONS/SIGNIFICANCE: Data are discussed in terms of recent findings showing a marked differentiation across different grasps during premovement phases which was carried over into subsequent movement phases. These findings offer a substantial contribution to the current debate about the nature of the sensorimotor transformations underlying grasping. And provide new insights into the detailed movement information contained in the human preparatory activity for specific hand movements.

Attachment style, affective loss and gray matter volume: a voxel-based morphometry study.

Early patterns of infant attachment have been shown to be an important influence on adult social behavior. Animal studies suggest that patterns of early attachment influence brain development, contributing to permanent alterations in neural structure; however, there are no previous studies investigating whether differences in attachment style are associated with differences in brain structure in humans. In this study, we used Magnetic Resonance Imaging (MRI) and voxel-based morphometry (VBM) to examine for the first time the association between attachment style, affective loss (for example, death of a loved one) and gray matter volume in a healthy sample of adults (n = 32). Attachment style was assessed on two dimensions (anxious and avoidant) using the ECR-Revised questionnaire. High attachment-related anxiety was associated with decreased gray matter in the anterior temporal pole and increased gray matter in the left lateral orbital gyrus. A greater number of affective losses was associated with increased gray matter volume in the cerebellum; in this region, however, the impact of affective losses was significantly moderated by the level of attachment-related avoidance. These findings indicate that differences in attachment style are associated with differences in the neural structure of regions implicated in emotion regulation. It is hypothesized that early attachment experience may contribute to structural brain differences associated with attachment style in adulthood; furthermore, these findings point to a neuronal mechanism through which attachment style may mediate individual differences in responses to affective loss.