Women's involvement in decision-making and association with reproductive health behaviors: findings from a cross-sectional survey in Niger.

BACKGROUND: Though women in Niger are largely responsible for the familial health and caretaking, prior research shows limited female autonomy in healthcare decisions. This study extends current understanding of women's participation in decision-making and its influence on reproductive health behaviors. METHODS: Cross-sectional survey with married women (15-49 years, N = 2,672) in Maradi and Zinder Niger assessed women's participation in household decision-making in health and non-health issues. Analyses examined [1] if participation in household decision-making was associated with modern contraceptive use, antenatal care (ANC) attendance, and skilled birth attendance at last delivery and [2] what individual, interpersonal, and community-level factors were associated with women's participation in decision-making. RESULTS: Only 16% of the respondents were involved-either autonomously or jointly with their spouse-in all three types of household decisions: (1) large purchase, (2) visiting family/parents, and (3) decisions about own healthcare. Involvement in decision making was significantly associated with increased odds of current modern contraceptive use [aOR:1.36 (95% CI: 1.06-1.75)] and four or more ANC visits during their recent pregnancy [aOR:1.34 (95% CI: 1.00-1.79)], when adjusting for socio-demographic characteristics. There was no significant association between involvement in decision-making and skilled birth attendance at recent delivery. Odds of involvement in decision-making was significantly associated with increasing age and household wealth status, listening to radio, and involvement in decision-making about their own marriage. CONCLUSION: Women's engagement in decision-making positively influences their reproductive health. Social and behavior change strategies to shift social norms and increase opportunities for women's involvement in household decision making are needed. For example, radio programs can be used to inform specific target groups on how women's decision-making can positively influence reproductive health while also providing specific actions to achieve change. Opportunities exist to enhance women's voice either before women enter marital partnerships or after (for instance, using health and social programming).

"When you live in good health with your husband, then your children are in good health ." A qualitative exploration of how households make healthcare decisions in Maradi and Zinder Regions, Niger.

BACKGROUND: Gender dynamics influence household-level decision-making about health behaviors and subsequent outcomes. Health and development programs in Niger are addressing gender norms through social and behavior change (SBC) approaches, yet not enough is known about how health care decisions are made and if gender-sensitive programs influence the decision-making process. METHODS: We qualitatively explored how households make decisions about family planning, child health, and nutrition in the Maradi and Zinder regions, Niger, within the context of a multi-sectoral integrated SBC program. We conducted 40 in-depth interviews with married women (n = 20) and men (n = 20) between 18 and 61 years of age. RESULTS: Male heads of household were central in health decisions, yet women were also involved and expressed the ability to discuss health issues with their husbands. Participants described three health decision-making pathways: (1st pathway) wife informs husband of health issue and husband solely decides on the solution; (2nd pathway) wife informs husband of health issue, proposes the solution, husband decides; and (3rd pathway) wife identifies the health issue and both spouses discuss and jointly identify a solution. Additionally, the role of spouses, family members, and others varied depending on the health topic: family planning was generally discussed between spouses, whereas couples sought advice from others to address common childhood illnesses. Many participants expressed feelings of shame when asked about child malnutrition. Participants said that they discussed health more frequently with their spouses' following participation in health activities, and some men who participated in husbands' schools (a group-based social and behavior change approach) reported that this activity influenced their approach to and involvement with household responsibilities. However, it is unclear if program activities influenced health care decision-making or women's autonomy. CONCLUSIONS: Women are involved to varying degrees in health decision-making. Program activities that focus on improving communication among spouses should be sustained to enhance women role in health decision-making. Male engagement strategies that emphasize spousal communication, provide health information, discuss household labor may enhance couple communication in Niger. Adapting the outreach strategies and messages by healthcare topic, such as couples counseling for family planning versus community-based nutrition messaging, are warranted.

Effect of masks on speech intelligibility in auralized classrooms.

This study explored the effects of wearing face masks on classroom communication. The effects of three different types of face masks (fabric, surgical, and N95 masks) on speech intelligibility (SI) presented to college students in auralized classrooms were evaluated. To simulate realistic classroom conditions, speech stimuli were presented in the presence of speech-shaped noise with a signal-to-noise ratio of +3 dB under two different reverberation times (0.4 s and 3.1 s). The use of fabric masks yielded a significantly greater reduction in SI compared to the other masks. Therefore, surgical masks or N95 masks are recommended in teaching environments.

Exploring survivor perceptions of pre-eclampsia and eclampsia in Nigeria through the health belief model.

BACKGROUND: In Nigeria, hypertensive disorders have become the leading cause of facility-based maternal mortality. Many factors influence pregnant women's health-seeking behaviors and perceptions around the importance of antenatal care. This qualitative study describes the care-seeking pathways of Nigerian women who suffer from pre-eclampsia and eclampsia. It identifies the influences - barriers and enablers - that affect their decision making, and proposes solutions articulated by women themselves to overcome the obstacles they face. Informing this study is the health belief model, a cognitive value-expectancy theory that provides a framework for exploring perceptions and understanding women's narratives around pre-eclampsia and eclampsia-related care seeking. METHODS: This study adopted a qualitative design that enables fully capturing the narratives of women who experienced pre-eclampsia and eclampsia during their pregnancy. In-depth interviews were conducted with 42 women aged 17-48 years over five months in 2015 from Bauchi, Cross River, Ebonyi, Katsina, Kogi, Ondo and Sokoto states to ensure representation from each geo-political zone in Nigeria. These qualitative data were analyzed through coding and memo-writing, using NVivo 11 software. RESULTS: We found that many of the beliefs, attitudes, knowledge and behaviors of women are consistent across the country, with some variation between the north and south. In Nigeria, women's perceived susceptibility and threat of health complications during pregnancy and childbirth, including pre-eclampsia and eclampsia, influence care-seeking behaviors. Moderating influences include acquisition of knowledge of causes and signs of pre-eclampsia, the quality of patient-provider antenatal care interactions, and supportive discussions and care seeking-enabling decisions with families and communities. These cues to action mitigate perceived mobility, financial, mistrust, and contextual barriers to seeking timely care and promote the benefits of maternal and newborn survival and greater confidence in and access to the health system. CONCLUSIONS: The health belief model reveals intersectional effects of childbearing norms, socio-cultural beliefs and trust in the health system and elucidates opportunities to intervene and improve access to quality and respectful care throughout a woman's pregnancy and childbirth. Across Nigerian settings, it is critical to enhance context-adapted community awareness programs and interventions to promote birth preparedness and social support.

Setting the global research agenda for community health systems: literature and consultative review.

BACKGROUND: Globally, there is renewed interest in and momentum for strengthening community health systems, as also emphasized by the recent Astana Declaration. Recent reviews have identified factors critical to successful community health worker (CHW) programs but pointed to significant evidence gaps. This review aims to propose a global research agenda to strengthen CHW programs. METHODS AND RESULTS: We conducted a search for extant systematic reviews on any intermediate factors affecting the effectiveness of CHW programs in February 2018. A total of 30 articles published after year 2000 were included. Data on research gaps were abstracted and summarized under headings based on predominant themes identified in the literature. Following this data gathering phase, two technical advisory groups comprised of experts in the field of community health-including policymakers, implementors, researchers, advocates and donors-were convened to discuss, validate, and prioritize the research gaps identified. Research gap areas that were identified in the literature and validated through expert consultation include selection and training of CHWs, community embeddedness, institutionalization of CHW programs (referrals, supervision, and supply chain), CHW needs including incentives and remuneration, governance and sustainability of CHW programs, performance and quality of care, and cost-effectiveness of CHW programs. Priority research questions included queries on effective policy, financing, governance, supervision and monitoring systems for CHWs and community health systems, implementation questions around the role of digital technologies, CHW preferences, and drivers of CHW motivation and retention over time. CONCLUSIONS: As international interest and investment in CHW programs and community health systems continue to grow, it becomes critical not only to analyze the evidence that exists, but also to clearly define research questions and collect additional evidence to ensure that CHW programs are effective, efficient, equity promoting, and evidence based. Generally, the literature places a strong emphasis on the need for higher quality, more robust research.

A conceptual framework for measuring community health workforce performance within primary health care systems.

BACKGROUND: With the 40th anniversary of the Declaration of Alma-Ata, a global effort is underway to re-focus on strengthening primary health care systems, with emphasis on leveraging community health workers (CHWs) towards the goal of achieving universal health coverage for all. Institutionalizing effective, sustainable community health systems is currently limited by a lack of standard metrics for measuring CHW performance and the systems they work within. Developed through iterative consultations, supported by the Bill & Melinda Gates Foundation and in partnership with USAID and UNICEF, this paper details a framework, list of indicators, and measurement considerations for monitoring CHW performance in low- and middle-income countries. METHODS: A review of peer-reviewed articles, reports, and global data collection tools was conducted to identify key measurement domains in monitoring CHW performance. Three consultations were successively convened with global stakeholders, community health implementers, advocates, measurement experts, and Ministry of Health representatives using a modified Delphi approach to build consensus on priority indicators. During this process, a structured, web-based survey was administered to identify the importance and value of specific measurement domains, sub-domains, and indicators determined through the literature reviews and initial stakeholder consultations. Indicators with more than 75% support from participants were further refined with expert qualitative input. RESULTS: Twenty-one sub-domains for measurement were identified including measurement of incentives for CHWs, supervision and performance appraisal, data use, data reporting, service delivery, quality of services, CHW absenteeism and attrition, community use of services, experience of services, referral/counter-referral, credibility/trust, and programmatic costs. Forty-six indicators were agreed upon to measure the sub-domains. In the absence of complete population enumeration and digitized health information systems, the quality of metrics to monitor CHW programs is limited. CONCLUSIONS: Better data collection approaches at the community level are needed to strengthen management of CHW programs and community health systems. The proposed list of metrics balances exhaustive and pragmatic measurement of CHW performance within primary healthcare systems. Adoption of the proposed framework and associated indicators by CHW program implementors may improve programmatic effectiveness, strengthen their accountability to national community health systems, drive programmatic quality improvement, and plausibly improve the impact of these programs.

Detecting and managing hypertensive disorders in pregnancy: a cross-sectional analysis of the quality of antenatal care in Nigeria.

BACKGROUND: Nigeria has one of the highest rates of maternal mortality in the world (576/100,000 births), with a significant proportion of death attributed to hypertensive disorders in pregnancy (HDPs). High quality antenatal care (ANC) plays a crucial role in early detection and management of HDPs. We conducted an assessment of quality of antenatal care, and its capacity to detect and manage HDPs, in two tiers of Nigerian facilities, with the aim of describing the state of service delivery and identifying the most urgent gaps. METHODS: Quality of antenatal care was assessed and compared between primary healthcare centers (PHCs) (n = 56) and hospitals (secondary + tertiary facilities, n = 39) in seven states of Nigeria. A cross-sectional design captured quality of care using facility inventory checklists, semi-structured interviews with healthcare providers and clients, and observations of ANC consultations. A quality of care framework and scoring system was established based on aspects of structure, process, and outcome. Average scores were compared using independent sample t-tests and measures of effect were assessed by multivariate linear regression. RESULTS: All domains of quality except provider interpersonal skills scored below 55%. The lowest overall scores were observed in provider knowledge (49.9%) and provider technical skill (47.7%). PHCs performed significantly worse than hospitals in all elements of quality except for provider interpersonal skills. Provider knowledge was significantly associated with their level of designation (i.e., obstetrician vs. other providers). CONCLUSIONS: In order to provide high quality care, ANC in Nigeria must experience massive improvements to inventory, infrastructure and provider knowledge and training. In particular, ANC programs in PHCs must be revitalized to minimize the disparity in quality of care provided between PHCs and hospitals. The relatively low quality of care observed may be contributing to Nigeria's high rate of maternal mortality and burden of disease attributed to HDPs.

Longitudinal speech perception and language performance in pediatric cochlear implant users: the effect of age at implantation.

OBJECTIVES: Few studies have examined the long-term effect of age at implantation on outcomes using multiple data points in children with cochlear implants. The goal of this study was to determine whether age at implantation has a significant, lasting impact on speech perception, language, and reading performance for children with prelingual hearing loss. DESIGN: A linear mixed-model framework was used to determine the effect of age at implantation on speech perception, language, and reading abilities in 83 children with prelingual hearing loss who received cochlear implants by the age of 4 years. The children were divided into two groups based on their age at implantation: (1) under 2 years of age and (2) between 2 and 3.9 years of age. Differences in model-specified mean scores between groups were compared at annual intervals from 5 to 13 years of age for speech perception, and 7 to 11 years of age for language and reading. RESULTS: After controlling for communication mode, device configuration, and preoperative pure-tone average, there was no significant effect of age at implantation for receptive language by 8 years of age, expressive language by 10 years of age, reading by 7 years of age. In terms of speech-perception outcomes, significance varied between 7 and 13 years of age, with no significant difference in speech-perception scores between groups at ages 7, 11, and 13 years. Children who used oral communication (OC) demonstrated significantly higher speech-perception scores than children who used total communication (TC). OC users tended to have higher expressive language scores than TC users, although this did not reach significance. There was no significant difference between OC and TC users for receptive language or reading scores. CONCLUSIONS: Speech perception, language, and reading performance continue to improve over time for children implanted before 4 years of age. The present results indicate that the effect of age at implantation diminishes with time, particularly for higher-order skills such as language and reading. Some children who receive cochlear implants after the age of 2 years have the capacity to approximate the language and reading skills of their earlier-implanted peers, suggesting that additional factors may moderate the influence of age at implantation on outcomes over time.

Chryseobacterium angstadtii sp. nov., isolated from a newt tank.

As part of an undergraduate microbiology course, a yellow-orange-pigmented, Gram-staining negative, rod-shaped, non-motile bacterial strain was isolated from a glass tank housing several red-spotted newts (Notophthalmus viridescens). The sequence of the 16S rRNA gene of this strain, designated KM(T), was 97.4-98.0 % similar to those of the type strains of Chryseobacterium luteum, C. shigense and C. vrystaatense, while the similarity levels for protein-coding genes were less than 94.7 % for rpoB, less than 92.1 % for groEL and less than 87.1 % for gyrB. These values are lower than for many other established distinct species. Polyphasic characterization and comparison to these relatives revealed that strain KM(T) was similar to other Chryseobacterium strains in that it contained MK-6 as its major respiratory quinone and phosphatidylethanolamine as the most abundant polar lipid, produced flexirubin-type pigments, oxidase and catalase and primarily contained the fatty acids iso-C15 : 0, iso-C17 : 1ω9c, iso-C17 : 0 3-OH and summed feature 3 (comprising C16 : 1ω6c and/or C16 : 1ω7c). Based on the results of this study, strain KM(T) represents a novel species, for which the name Chryseobacterium angstadtii sp. nov. is proposed. The type strain is KM(T) ( = ATCC BAA-2160(T) = NRRL B-59516(T) = KCTC 23297(T)).

Talker-identification training using simulations of binaurally combined electric and acoustic hearing: generalization to speech and emotion recognition.

Understanding speech in background noise, talker identification, and vocal emotion recognition are challenging for cochlear implant (CI) users due to poor spectral resolution and limited pitch cues with the CI. Recent studies have shown that bimodal CI users, that is, those CI users who wear a hearing aid (HA) in their non-implanted ear, receive benefit for understanding speech both in quiet and in noise. This study compared the efficacy of talker-identification training in two groups of young normal-hearing adults, listening to either acoustic simulations of unilateral CI or bimodal (CI+HA) hearing. Training resulted in improved identification of talkers for both groups with better overall performance for simulated bimodal hearing. Generalization of learning to sentence and emotion recognition also was assessed in both subject groups. Sentence recognition in quiet and in noise improved for both groups, no matter if the talkers had been heard during training or not. Generalization to improvements in emotion recognition for two unfamiliar talkers also was noted for both groups with the simulated bimodal-hearing group showing better overall emotion-recognition performance. Improvements in sentence recognition were retained a month after training in both groups. These results have potential implications for aural rehabilitation of conventional and bimodal CI users.

Assessing spoken word recognition in children who are deaf or hard of hearing: a translational approach.

Under natural conditions, listeners use both auditory and visual speech cues to extract meaning from speech signals containing many sources of variability. However, traditional clinical tests of spoken word recognition routinely employ isolated words or sentences produced by a single talker in an auditory-only presentation format. The more central cognitive processes used during multimodal integration, perceptual normalization, and lexical discrimination that may contribute to individual variation in spoken word recognition performance are not assessed in conventional tests of this kind. In this article, we review our past and current research activities aimed at developing a series of new assessment tools designed to evaluate spoken word recognition in children who are deaf or hard of hearing. These measures are theoretically motivated by a current model of spoken word recognition and also incorporate "real-world" stimulus variability in the form of multiple talkers and presentation formats. The goal of this research is to enhance our ability to estimate real-world listening skills and to predict benefit from sensory aid use in children with varying degrees of hearing loss.

Pathways to service access for pre-eclampsia and eclampsia in rural Bangladesh: Exploring women's care-seeking.

BACKGROUND: While women in low- and middle-income countries face a range of barriers to accessing care for hypertensive disorders of pregnancy, there is little understanding of the pathways taken to overcome these constraints and reach the services they need. This study explores the perspectives of women and communities on the influences that impact care-seeking decisions and pathways to health services. METHODS: To understand individual perspectives, we conducted 22 in-depth interviews (IDIs) with pre-eclampsia and eclampsia survivors (PE/E) in a tertiary hospital, where they received care after initiating PE/E services in different parts of the country. In four districts, we conducted one male and one female focus group discussion (FGD) to unearth care-seeking pathways and explore normative perspectives and the range of internal and external influences. Careful thematic analysis using Atlas-ti was applied. RESULTS: Prevailing views of women and communities across settings in Bangladesh indicate varied pathways to care throughout their pregnancy, during childbirth, and in the postnatal period influenced by internal and external factors at the individual, familial, social, and health systems levels. Internal influences draw on women's own awareness of hypertension complications and options, and their ability to decide to seek care. External factors include social influences like family and community norms, culturally-accepted alternatives, and community perceptions of the health system's capacity to provide quality care. The interaction of these factors often delay care seeking and can lead to complex pathways to care. CONCLUSION: Women's individual pathways to care were diverse, despite the homogenous community perceptions of the influences on women's care-seeking behaviors. This finding supports the need for improving quality of care in primary healthcare facilities and strengthening gender equity and community-based promotion activities through targeted policy and programming.

Introduction of digital reporting platform to integrate community-level data into health information systems is feasible and acceptable among various community health stakeholders: A mixed-methods pilot study in Mopti, Mali.

BACKGROUND: Integration of community-level health data within Mali's web-based District Health Information System (DHIS2) is underexplored. This study conducted in Mopti, Mali examined challenges and enablers affecting integration and investigated how digital technology optimizes data quality, availability, and use. METHODS: This pre-post mixed-methods study compared community health workers' (CHWs') experiences reporting routine community-level data using the DHIS2 digital application on tablets and paper forms. 141 CHWs participated in quantitative surveys and focus group discussions at baseline and endline. In-depth interviews were conducted with 18 and eight CHW supervisors and 12 and 11 other stakeholders at baseline and endline, respectively. We calculated changes in CHW performance, and job satisfaction among intervention and comparison groups using the difference-in-difference (DID) estimator controlling for baseline characteristics. Routine longitudinal DHIS2 data described timeliness and completeness of CHW reporting. Thematic analysis of qualitative data explained implementation challenges and enablers, and considerations for data use. RESULTS: The median number of health talks and household visits among intervention group CHWs increased from baseline to endline compared to the comparison group (DID estimator; P < 0.05 for both), as did aspects of job satisfaction (satisfaction with opportunities to contribute ideas to improve services and coordination with supervisors and stakeholders, P < 0.1). CHWs reported high levels of comfort and confidence navigating the tablet for data collection and on-time reporting. While CHWs experienced challenges -tablet quality, limited network connection and increased workload, they preferred the digital to paper system. Stakeholder, supervisor and CHW roles in data review and decision-making appear unchanged from baseline to endline, though some supervisors found the tablets improved data timeliness and completeness. Routine longitudinal DHIS2 data confirm high rates of data timeliness and completeness before and after the intervention, with little or no change over time. CONCLUSIONS: CHW tablet use for data collection and reporting is feasible and desirable, however, program and policy changes are needed for this to be a fully-functional system. Future efforts need to consider how to ensure site-level network connectivity; quality, compatibility and functionality of digital technology; and routine supportive systems for CHWs and community health actors on data use.

Assessing vaccine introduction and uptake timelines in Gavi-supported countries: are introduction timelines accelerating across vaccine delivery platforms?

BACKGROUND: Previous studies identified factors influencing regulatory approval to introduction timelines for individual vaccines. However, introduction and uptake timelines have not been comprehensively assessed across the portfolio of Gavi-supported vaccines. METHODS: We analysed median times between introduction milestones from vaccine licensure to country introduction and uptake across six vaccine-preventable diseases (VPDs), three delivery platforms and 69 Gavi-supported countries. Data were gathered from public, partner and manufacturer records. VPDs and prequalified vaccines analysed included Haemophilus influenzae type b (DTwP-HepB-Hib, pentavalent), pneumococcal disease (pneumococcal conjugate vaccine, PCV), rotavirus diarrhoea (rotavirus vaccine, RVV), cervical cancer (human papillomavirus vaccine, HPV), polio (inactivated polio vaccine, IPV) and meningococcal meningitis (meningococcal group A conjugate vaccine, MenA). RESULTS: Median time from first vaccine licensure to first Gavi-supported country introduction across VPDs at a 'global level' (Gavi-supported countries) was 5.4 years. Once licensed, MenA vaccines reached first introduction fastest (campaign=0.6 years; routine immunisation (RI)=1.7 years). Most introductions were delayed. Country uptake following first introduction was accelerated for more recently Gavi-supported RI vaccines compared with older ones. CONCLUSION: Factors accelerating timelines across delivery platforms included rapid product prequalifications by WHO, strong initial recommendations by the WHO Strategic Advisory Group of Experts (SAGE) on Immunization, achieving target product profiles on first vaccine licensure within a VPD and completing several VPD milestones at a global level prior to licensure. Milestones required for introduction in Gavi-supported countries should start prior or in parallel to licensure to accelerate uptake of vaccines delivered through diverse delivery platforms.

Exploring experiences of infertility amongst women and men in low-income and middle-income countries: protocol for a qualitative systematic review.

INTRODUCTION: Infertility is increasingly recognised as a global public health issue for women and men that merits further investigation to support policy and programming. While research in high-income settings has examined the consequences of infertility and access to services, there has been limited synthesis of how individuals experience infertility in low-income and middle-income countries (LMICs). This protocol describes a systematic review that will synthesise qualitative evidence on experiences of infertility among women and men in LMICs. METHODS AND ANALYSIS: The review will follow the Enhancing transparency in reporting the synthesis of qualitative research (ENTREQ) guidelines for reporting on qualitative evidence syntheses. The study team will search for published literature in PubMed, CINAHL and Scopus and PsycINFO databases and review available grey literature. Using Covidence software, two independent reviewers will conduct title and abstract screening based on inclusion and exclusion criteria, followed by full-text reviews and extraction by a larger team. Quality will be appraised using an adapted version of the Critical Appraisal Skills Programme guidelines. We will conduct thematic synthesis to characterise individual experiences and related factors at the individual, interpersonal, community and health system levels. We will develop a conceptual framework to describe evidence on experiences of infertility in LMICs and to help inform interventions across settings. ETHICS AND DISSEMINATION: This protocol has been internally approved as exempt by the Institutional Review Board of the Population Council, as it does not involve contact with human subjects or personally identifying data. Results of the review will be published in a peer-reviewed journal and will be used to inform future infertility research and programming in LMICs. PROSPERO REGISTRATION NUMBER: CRD42021227742.

Development and validation of a multi-dimensional scale to assess community health worker motivation.

BACKGROUND: Ensuring that Community Health Workers (CHWs) are motivated is critical to their performance, retention and well-being - and ultimately to the effectiveness of community health systems worldwide. While CHW motivation is as multi-dimensional construct, there is no multi-dimensional measure available to guide programming. In this study, we developed and validated a pragmatic, multi-dimensional measure of CHW motivation. METHODS: Scale validation entailed qualitative and survey research in Mali and Bangladesh. We developed a pool of work satisfaction items as well as several items assessing the importance of hypothesized sub-dimensions of motivation, based on the literature and expert consultations. Qualitative research helped finalize scale sub-dimensions and items. We tested the scale in surveys with CHWs in Mali (n = 152, 40% female, mean age 32) and Bangladesh (n = 76 women, mean age 46). We applied a split-sample exploratory/confirmatory factor analysis (EFA/CFA) in Mali, and EFA in Bangladesh, then assessed reliability. We also gauged convergent/predictive validity, assessing associations between scale scores with conceptually related variables. RESULTS: The final 22-item scale has four sub-dimensions: Quality of supervision, Feeling valued and capacitated in your work, Peer respect and support, and Compensation and workload. Model fit in CFAs was good, as were reliabilities for the full scale (alpha: 0.84 in Mali, 0.93 in Bangladesh) and all sub-dimensions. To construct scores for the final scale, we weighted the scores for each sub-dimension by CHW-reported importance of that sub-dimension. Final possible range was -6 to +6 (sub-dimensions), -24 to +24 (full scale). Mean (standard deviation) of full-scale scores were 5.0 (3.3) in Mali and 14.5 (5.3) in Bangladesh. In both countries, higher motivation was significantly associated with higher overall interest in their work, feeling able to improve health/well-being in their community, as well as indicators of higher performance and retention. CONCLUSIONS: We found that the Multi-dimensional Motivation (MM) scale for CHWs is a valid and reliable measure that comprehensively assesses motivation. We recommend the scale be employed in future research around CHW performance and community health systems strengthening worldwide. The scale should be further evaluated within longitudinal studies assessing CHW performance and retention outcomes over time.

Lexical effects on spoken-word recognition in children with normal hearing.

OBJECTIVES: This study is the first in a series designed to develop and norm new theoretically motivated sentence tests for children. The purpose was to examine the independent contributions of word frequency (i.e., how often words occur in language) and lexical density (the number of similar sounding words or "neighbors" to a target word) to the perception of key words in the new sentence set. DESIGN: Twenty-four children with normal hearing aged 5 to 12 yrs served as participants; they were divided into four equal age-matched groups. The stimuli consisted of 100 semantically neutral sentences that were 5 to 7 words in length. Each sentence contained 3 key words that were controlled for word frequency and lexical density. Words with few neighbors come from sparse neighborhoods, whereas words with many neighbors come from dense neighborhoods. The key words within a sentence belonged to one of the four lexical categories: (1) high-frequency sparse, (2) low-frequency dense, (3) high-frequency dense, and (4) low-frequency sparse. Participants were administered the sentence list and the 300 key words in isolation at 65 dB SPL. Each participant group was tested in spectrally matched noise at one of the four signal-to-noise ratios (SNRs -2, 0, 2, and 4 dB). The percent of words correctly identified was calculated as a function of SNR, key word context (sentences vs. words), and key word lexical category. RESULTS: SNR had a significant effect on the recognition of key words in sentences and in isolation; performance improved at higher SNRs. There were significant main effects of word frequency and lexical density as well as a significant interaction between the two lexical factors. In isolation, high-frequency words were recognized more accurately than low-frequency words. In both word and sentence contexts, sparse words yielded greater accuracy than dense words, irrespective of word frequency. There was a modest but significant negative correlation between lexical density and the recognition of words in isolation and in sentences. CONCLUSIONS: Word frequency and lexical density seem to influence word recognition independently in children with normal hearing. This is similar to earlier results in adults with normal hearing. In addition, there seems to be an interaction between the two factors, with lexical density being more heavily weighted than word frequency. These results give us further insight into the way children organize and access words from long-term lexical memory in a relational way. Our results showed that lexical effects were most evident at poorer SNRs. This may have important implications for assessing spoken-word recognition performance in children with sensory aids because they typically receive a degraded auditory signal.

Abnormal micronuclear telomeres lead to an unusual cell cycle checkpoint and defects in Tetrahymena oral morphogenesis.

Telomere mutants have been well studied with respect to telomerase and the role of telomere binding proteins, but they have not been used to explore how a downstream morphogenic event is related to the mutated telomeric DNA. We report that alterations at the telomeres can have profound consequences on organellar morphogenesis. Specifically, a telomerase RNA mutation termed ter1-43AA results in the loss of germ line micronuclear telomeres in the binucleate protozoan Tetrahymena thermophila. These cells also display a micronuclear mitotic arrest, characterized by an extreme delay in anaphase with an elongated, condensed chromatin and a mitotic spindle apparatus. This anaphase defect suggests telomere fusions and consequently a spindle rather than a DNA damage checkpoint. Most surprisingly, these mutants exhibit unique, dramatic defects in the formation of the cell's oral apparatus. We suggest that micronuclear telomere loss leads to a "dynamic pause" in the program of cortical development, which may reveal an unusual cell cycle checkpoint.

Using early language outcomes to predict later language ability in children with cochlear implants.

The increased access to sound that cochlear implants have provided to profoundly deaf children has allowed them to develop English speech and language skills more successfully than using hearing aids alone. The purpose of this study was to determine how well early postimplant language skills were able to predict later language ability. Thirty children who received a cochlear implant between the years 1991 and 2000 were study participants. The Reynell Developmental Language Scales (RDLS) and the Clinical Evaluation of Language Fundamentals (CELF) were used as language measures. Results revealed that early receptive language skills as measured using the RDLS were good predictors of later core language ability assessed by the CELF. Alternatively, early expressive language skills were not found to be good predictors of later language performance. The age at which a child received an implant was found to have a significant impact on the early language measures, but not the later language measure, or on the ability of the RDLS to predict performance on the CELF measure.

Language skills of profoundly deaf children who received cochlear implants under 12 months of age: a preliminary study.

CONCLUSION: This study demonstrated that children who receive a cochlear implant below the age of 2 years obtain higher mean receptive and expressive language scores than children implanted over the age of 2 years. OBJECTIVE: The purpose of this study was to compare the receptive and expressive language skills of children who received a cochlear implant before 1 year of age to the language skills of children who received an implant between 1 and 3 years of age. SUBJECTS AND METHODS: Standardized language measures, the Reynell Developmental Language Scale (RDLS) and the Preschool Language Scale (PLS), were used to assess the receptive and expressive language skills of 91 children who received an implant before their third birthday. RESULTS: The mean receptive and expressive language scores for the RDLS and the PLS were slightly higher for the children who were implanted below the age of 2 years compared with the children who were implanted over 2 years old. For the PLS, both the receptive and expressive mean standard scores decreased with increasing age at implantation.