Understanding why at-risk population segments do not seek care for tuberculosis: a precision public health approach in South India.

INTRODUCTION: Delaying care-seeking for tuberculosis (TB) symptoms is a major contributor to mortality, leading to worse outcomes and spread. To reduce delays, it is essential to identify barriers to care-seeking and target populations most at risk of delaying. Previous work identifies barriers only in people within the health system, often long after initial care-seeking. METHODS: We conducted a community-based survey of 84 625 households in Chennai, India, to identify 1667 people with TB-indicative symptoms in 2018-2019. Cases were followed prospectively to observe care-seeking behaviour. We used a comprehensive survey to identify care-seeking drivers, then performed multivariate analyses to identify care-seeking predictors. To identify profiles of individuals most at risk to delay care-seeking, we segmented the sample using unsupervised clustering. We then estimated the per cent of the TB-diagnosed population in Chennai in each segment. RESULTS: Delayed care-seeking characteristics include smoking, drinking, being employed, preferring different facilities than the community, believing to be at lower risk of TB and believing TB is common. Respondents who reported fever or unintended weight loss were more likely to seek care. Clustering analysis revealed seven population segments differing in care-seeking, from a retired/unemployed/disabled cluster, where 70% promptly sought care, to a cluster of employed men who problem-drink and smoke, where only 42% did so. Modelling showed 54% of TB-diagnosed people who delay care-seeking might belong to the latter segment, which is most likely to acquire TB and least likely to promptly seek care. CONCLUSION: Interventions to increase care-seeking should move from building general awareness to addressing treatment barriers such as lack of time and low-risk perception. Care-seeking interventions should address specific beliefs through a mix of educational, risk perception-targeting and social norms-based campaigns. Employed men who problem-drink and smoke are a prime target for interventions. Reducing delays in this group could dramatically reduce TB spread.

Facilities are substantially more influential than care providers in the quality of delivery care received: a variance decomposition and clustering analysis in Kenya, Malawi and India.

INTRODUCTION: Improving the quality of care during childbirth is essential for reducing neonatal and maternal mortality. One barrier to improving quality of care is understanding the appropriate level to target interventions. We examine quality of care data during labour and delivery from multiple countries to assess whether quality varies primarily from nurse to nurse within the same facility, or primarily between facilities. METHODS: To assess the relative contributions of nurses and facilities to variance in quality of care, we performed a variance decomposition analysis using a linear mixed effect model on two data sources: (1) the number of vital signs assessed for women in labour from a study of nurse practices in Uttar Pradesh, India; 2) broad-scale indices of respectful and competent care generated from Service Provision Assessments in Kenya and Malawi. We used unsupervised clustering, a data mining technique that groups objects together based on similar characteristics, to identify groups of facilities that displayed distinct patterns of vital signs assessment behaviour. RESULTS: We found 3-10 times more variance in quality of care was explained by the facility where a patient received care than by the nurse who provided it. The unsupervised clustering analysis revealed groups of facilities with highly distinct patterns of vital signs assessment, even when overall rates of vital signs assessments were similar (eg, some facilities consistently test fetal heart rate, but not other vitals, others only blood pressure). CONCLUSION: Facilities within a region can vary substantially in the quality of care they provide to women in labour, but within a facility, nurses tend to provide similar care. This holds true both for care that can be influenced by equipment availability and technical training (eg, vital signs assessment), as well as cultural aspects (eg, respectful care).

If all your friends jumped off a bridge: the effect of others' actions on engagement in and recommendation of risky behaviors.

There is a large gap between the types of risky behavior we recommend to others and those we engage in ourselves. In this study, we hypothesized that a source of this gap is greater reliance on information about others' behavior when deciding whether to take a risk oneself than when deciding whether to recommend it to others. To test this hypothesis, we asked participants either to report their willingness to engage in a series of risky behaviors themselves; their willingness to recommend those behaviors to a loved one; or, how good of an idea it would be for either them or a loved one to engage in the behaviors. We then asked them to evaluate those behaviors on criteria related to the expected utility of the risk (benefits, costs, and likelihood of costs), and on engagement in the activity by people they knew. We found that, after accounting for effects of perceived benefit, cost, and likelihood of cost, perceptions of others' behavior had a dramatically larger impact on participants' willingness to engage in a risk than on their willingness to recommend the risk or their prescriptive evaluation of the risk. These findings indicate that the influence of others' choices on risk-taking behavior is large, direct, cannot be explained by an economic utility model of risky decision-making, and goes against one's own better judgment.

Predicting risky choices from brain activity patterns.

Previous research has implicated a large network of brain regions in the processing of risk during decision making. However, it has not yet been determined if activity in these regions is predictive of choices on future risky decisions. Here, we examined functional MRI data from a large sample of healthy subjects performing a naturalistic risk-taking task and used a classification analysis approach to predict whether individuals would choose risky or safe options on upcoming trials. We were able to predict choice category successfully in 71.8% of cases. Searchlight analysis revealed a network of brain regions where activity patterns were reliably predictive of subsequent risk-taking behavior, including a number of regions known to play a role in control processes. Searchlights with significant predictive accuracy were primarily located in regions more active when preparing to avoid a risk than when preparing to engage in one, suggesting that risk taking may be due, in part, to a failure of the control systems necessary to initiate a safe choice. Additional analyses revealed that subject choice can be successfully predicted with minimal decrements in accuracy using highly condensed data, suggesting that information relevant for risky choice behavior is encoded in coarse global patterns of activation as well as within highly local activation within searchlights.

Validation of a child-friendly version of the monetary incentive delay task.

The monetary incentive delay (MID) task (Knutson, 2000) is an imaging paradigm used to measure neural activity of incentive receipt anticipation. The task reliably elicits striatal activation and is commonly used with both adult and adolescent populations, but is not designed for use with children. In the current article, we present data on the newly designed 'piñata task' a child-friendly analog of the MID task. We demonstrate the task can be used successfully in children to study the neural correlates of anticipatory incentive processing. Results from a behavioral study and a neuroimaging study are reported. In Study #1, a sample of 8- to 14-year-old children demonstrates expected behavioral effects: subjects responded most quickly and most accurately on trials with greater potential rewards; older children displayed faster reaction times than younger. In Study #2, 8- to 12-year-old children showed neural activation patterns consistent with those seen in adults in the MID task: activation was modulated by cue incentive value in reward-processing regions, including the striatum, thalamus, mesial prefrontal cortex and insula. Study results suggest that the piñata task is a valid analog of the MID task, and can be used to assess neural correlates of reward processing in children as young as 8-9 years of age.

Approach-withdrawal and the role of the striatum in the temperament of behavioral inhibition.

Behavioral inhibition is a temperament characterized in infancy and early childhood by a tendency to withdraw from novel or unfamiliar stimuli. Children exhibiting this disposition, relative to children with other dispositions, are more socially reticent, less likely to initiate interaction with peers, and more likely to develop anxiety over time. Until recently, a dominant model attributed this disposition to reductions in the threshold for engaging the circuitry supporting fear learning, particularly the amygdala. Recent work, however, also has implicated striatal circuitry and other regions that constitute components of a presumed reward system. A series of studies found that behaviorally inhibited adolescents display heightened activation of striatal structures to cues indicating an opportunity to receive reward. This article reviews evidence implicating dual roles for fear and reward circuitry in the expression of behavioral inhibition.

Striatal responses to negative monetary outcomes differ between temperamentally inhibited and non-inhibited adolescents.

The present study compared blood oxygen level dependent (BOLD) response in behaviorally inhibited and behaviorally non-inhibited adolescents to positive and negative feedback following their choice in a reward task. Previous data in these same subjects showed enhanced activation in striatal areas in behaviorally inhibited subjects to cues predicting gain or a loss. However, no analyses had examined responses following actual gains or losses. Relative to non-inhibited subjects, behaviorally inhibited subjects in the current study showed enhanced caudate response to negative but not positive feedback, indicating that striatal sensitivity to feedback may be specific to aversive information. In addition, compared to non-inhibited subjects, behaviorally inhibited subjects exhibited reduced differentiation between positive and negative feedback in ventromedial prefrontal cortex (vmPFC). This suggests a perturbed ability to encode reward value.

Role of attention in the regulation of fear and anxiety.

Emotion regulation makes use of specific aspects of attention and executive functions that are critical for the development of adaptive social functioning, and perturbations in these processes can result in maladaptive behavior and psychopathology. Both involuntary and voluntary attention processes have been examined at both the behavioral and the neural levels and are implicated in the maintenance of fearful or anxious behaviors. However, relatively little is known about how these attention processes come to influence emotional behavior across development. The current review summarizes the extant literature on the links between voluntary and involuntary attention processes and the role that these attention processes have in the etiology, maintenance, and regulation of anxious behavior.

Startle response in behaviorally inhibited adolescents with a lifetime occurrence of anxiety disorders.

OBJECTIVE: Behaviorally inhibited children face increased risk for anxiety disorders, although factors that predict which children develop a disorder remain poorly specified. The current study examines whether the startle reflex response may be used to differentiate between behaviorally inhibited adolescents with and without a history of anxiety. METHOD: Participants were assessed for behavioral inhibition during toddlerhood and early childhood. They returned to the laboratory as adolescents and completed a fear-potentiated startle paradigm and a clinical diagnostic interview (Schedule for Affective Disorders and Schizophrenia for School-Age Children-Present and Lifetime Version). Magnitude of the startle reflex was examined at baseline and during cues associated with safety and threat. RESULTS: Only adolescents who showed high levels of behavioral inhibition and had a lifetime occurrence of anxiety disorders showed increased startle reactivity in the presence of safety cues. Neither behavioral inhibition nor diagnosis was related to startle reactivity during threat cues. CONCLUSIONS: These results suggest that neurobiological measures, such as the startle reflex, may be a potential risk marker for the development of anxiety disorders among behaviorally inhibited adolescents. These methods may enhance our ability to identify vulnerable individuals before the development of anxious psychopathology.

Challenges in developing novel treatments for childhood disorders: lessons from research on anxiety.

Alterations in brain development may contribute to chronic mental disorders. Novel treatments targeted toward the early-childhood manifestations of such chronic disorders may provide unique therapeutic opportunities. However, attempts to develop and deliver novel treatments face many challenges. Work on pediatric anxiety disorders illustrates both the inherent challenges as well as the unusual opportunities for therapeutic advances. The present review summarizes three aspects of translational research on pediatric anxiety disorders as the work informs efforts to develop novel interventions. First, the review summarizes data on developmental conceptualizations of anxiety from both basic neuroscience and clinical perspectives. This summary is integrated with a discussion of the two best-established treatments, cognitive behavioral therapy and selective serotonin reuptake inhibitors. Second, the review summarizes work on attention bias to threat, considering implications for both novel treatments and translational research on neural circuitry functional development. This illustrates the manner in which clinical findings inform basic systems neuroscience research. Finally, the review summarizes work in basic science on fear learning, as studied in fear conditioning, consolidation, and extinction paradigms. This summary ends by describing potential novel treatments, illustrating the manner in which basic neuroscience informs therapeutics.

Affective primes suppress attention bias to threat in socially anxious individuals.

Anxious individuals show an attention bias towards threatening information. However, under conditions of sustained environmental threat this otherwise-present attention bias disappears. It remains unclear whether this suppression of attention bias can be caused by a transient activation of the fear system. In the present experiment, high socially anxious and low socially anxious individuals (HSA group, n=12; LSA group, n=12) performed a modified dot-probe task in which they were shown either a neutral or socially threatening prime word prior to each trial. EEG was collected and ERP components to the prime and faces displays were computed. HSA individuals showed an attention bias to threat after a neutral prime, but no attention bias after a threatening prime, demonstrating that suppression of attention bias can occur after a transient activation of the fear system. LSA individuals showed an opposite pattern: no evidence of a bias to threat with neutral primes but induction of an attention bias to threat following threatening primes. ERP results suggested differential processing of the prime and faces displays by HSA and LSA individuals. However, no group by prime interaction was found for any of ERP components.