Unsupervised mobile cognitive testing for use in preclinical Alzheimer's disease.

INTRODUCTION: Unsupervised digital cognitive testing is an appealing means to capture subtle cognitive decline in preclinical Alzheimer's disease (AD). Here, we describe development, feasibility, and validity of the Boston Remote Assessment for Neurocognitive Health (BRANCH) against in-person cognitive testing and amyloid/tau burden. METHODS: BRANCH is web-based, self-guided, and assesses memory processes vulnerable in AD. Clinically normal participants (n = 234; aged 50-89) completed BRANCH; a subset underwent in-person cognitive testing and positron emission tomography imaging. Mean accuracy across BRANCH tests (Categories, Face-Name-Occupation, Groceries, Signs) was calculated. RESULTS: BRANCH was feasible to complete on participants' own devices (primarily smartphones). Technical difficulties and invalid/unusable data were infrequent. BRANCH psychometric properties were sound, including good retest reliability. BRANCH was correlated with in-person cognitive testing (r = 0.617, P < .001). Lower BRANCH score was associated with greater amyloid (r = -0.205, P = .007) and entorhinal tau (r = -0.178, P = .026). DISCUSSION: BRANCH reliably captures meaningful cognitive information remotely, suggesting promise as a digital cognitive marker sensitive early in the AD trajectory.

Home-based records for poor mothers and children in Afghanistan, a cross sectional population based study.

BACKGROUND: No studies have examined distribution, retention and use of maternal and child health (MCH) home-based records (HBRs) in the poorest women in low income countries. Our primary objective was to compare distribution of the new Afghanistan MCH HBR (the MCH handbook) to the poorest women (quintiles 1-2) with the least poor women (quintiles 3-5). Secondary objectives were to assess distribution, retention and use of the handbook across wealth, education, age and parity strata. METHODS: This was a population based cross sectional study set in Kama and Mirbachakot districts of Afghanistan from August 2017 to April 2018. Women were eligible to be part of the study if they had a child born in the last 6 months. Multivariable logistic regression models were constructed to adjust for clustering by district and potential confounders decided a priori (maternal education, maternal age, parity, age of child, sex of child) and to calculate adjusted odds ratios (aOR), 95% confidence intervals (95% CI) and corresponding p values. Principal components analysis was used to create the wealth quintiles using standard methods. Wealth categories were 'poorest' (quintiles 1,2) and 'least poor' (quintiles 3,4,5). RESULTS: 1728/1943 (88.5%) mothers received a handbook. The poorest women (633, 88.8%) had similar odds of receiving a handbook compared to the least poor (990, 91.7%) (aOR 1.26, 95%CI [0.91-1.77], p value 0.165). Education status (aOR 1.03, 95%CI [0.63-1.68], p value 0.903) and age (aOR 1.39, 95%CI [0.68-2.84], p value 0.369) had little effect. Multiparous women (1371, 91.5%) had a higher odds than primiparous women (252, 85.7%) (aOR 1.83, 95%CI [1.16-2.87], p value 0.009). Use of the handbook by health providers and mothers was similar across quintiles. Ten (0.5%) women reported that they received a book but then lost it. CONCLUSIONS: We were able to achieve almost universal coverage of our new MCH HBR in our study area in Afghanistan. The handbook will be scaled up over the next three years across all of Afghanistan and will include close monitoring and assessment of coverage and use by all families.

Conditional cash transfers to improve use of health facilities by mothers and newborns in conflict affected countries, a prospective population based intervention study from Afghanistan.

BACKGROUND: The effects of conditional cash transfer (CCT) programs on maternal and child health (MCH) service use in conflicted affected countries such as Afghanistan are not known. METHODS: We conducted a non-randomised population based intervention study in six Afghanistan districts from December 2016 to December 2017. Six control districts were purposively matched. Women were eligible to be included in the baseline and endline evaluation surveys if they had given birth to one or more children in the last 12 months. The intervention was a CCT program including information, education, communication (IEC) program about CCT to community members and financial incentives to community health workers (CHWs) and families if mothers delivered their child at a health facility. Control districts received standard care. The primary objective was to assess the effect of CCT on use of health facilities for delivery. Secondary objectives were to assess the effect of CCT on antenatal care (ANC), postnatal care (PNC) and CHW motivation to perform home visits. Outcomes were analysed at 12 months using multivariable difference-in-difference linear regression models adjusted for clustering and socio demographic variables. RESULTS: Overall, facility delivery increased in intervention villages by 14.3% and control villages by 8.4% (adjusted mean difference [AMD] 3.3%; 95% confidence interval [- 0.14 to 0.21], p value 0.685). There was no effect in the poorest quintile (AMD 0.8% [- 0.30 to 0.32], p value 0.953). ANC (AMD 45.0% [0.18 to 0.72] p value 0.004) and PNC (AMD 31.8% [- 0.05 to 0.68] p value 0.080) increased in the intervention compared to the control group. CHW home visiting changed little in intervention villages (- 3.0%) but decreased by - 23.9% in control villages (AMD 12.2% [- 0.27 to 0.51], p value 0.508). CCT exposure was 27.3% (342/1254) overall and 10.2% (17/166) in the poorest quintile. CONCLUSIONS: Our study demonstrated that a CCT program provided to women aged 16-49 years can be implemented in a highly conservative conflict affected population. CCT should be scaled up for the poorest women in Afghanistan.

Getting health information to internally displaced youth in Afghanistan: can mobile phone technology bridge the gap?

Background: Afghanistan ranks among the most disadvantaged globally for many key reproductive, maternal, newborn and child health (RMNCH) indicators, despite important gains in the past decade. Youth (15 to 24 years) are a key audience for RMNCH information as they enter adulthood, marry and begin families; however, reaching Afghan youth with health information is challenging. Internally displaced persons (IDPs), including youth, experience additional challenges to obtaining health-related information and services. This study measured current and preferred RMNCH information channels to explore the feasibility of using mobile phone technology to provide RMNCH information to IDP youth in Afghanistan. Methods: We conducted a sub-group analysis of survey data from a mixed-methods, cross-sectional, formative assessment to understand current access to RMNCH information. The target population for this analysis includes 15-25-year-old male and female IDP youth from three Afghan Provinces. Survey data were collected using a structured questionnaire administered through face-to-face interviews. Data were analyzed descriptively. Results: A total of 450 IDP youth were surveyed in the three provinces (225 male and 225 female). Access to RMNCH information outside of health facilities was limited. Mobile phone ownership was nearly universal among male participants, yet considerably lower among females; nearly all participants without personal phones reported access to phones when needed. Although few participants spontaneously mentioned mobile phones as a preferred source of RMNCH information, most male and female respondents reported they would be very or somewhat likely to use a free, mobile-phone-based system to access such information if offered. Conclusions: Given widespread access and considerable interest voiced by participants, mobile phones may be a viable way to reach IDP youth with important RMNCH health information in this fragile setting. Interventions should be designed and pilot-tested to identify the most appropriate platforms and information content and to further document feasibility and acceptability.

Barriers associated with care-seeking for institutional delivery among rural women in three provinces in Afghanistan.

BACKGROUND: In the past fifteen years, Afghanistan has made substantial progress in extending primary health care. However, coverage of essential health interventions proven to improve maternal and neonatal health outcomes, particularly skilled birth attendance, remains unacceptably low. This is especially true for those in the poorest quintile of the population. This cross-sectional quantitative and qualitative study assessed barriers associated with care-seeking for institutional delivery among rural Afghan women in three provinces. METHODS: The study was conducted from November to December 2016 in 12 districts across three provinces - Badghis, Bamyan, and Kandahar - which are predominately rural. Districts were used as the primary sampling unit with district-level sample sizes reflecting the ratio of that district's population to provincial population. Villages within these districts, the secondary sampling units, were randomly selected. A household survey was used to collect data on: demographics, socio-economic status, childbearing history, health transport and service costs, maternal health seeking behavior and barriers to service uptake. Data on barriers to facility delivery were compared across provinces using chi square tests. RESULTS: Of the 2479 women of child bearing age interviewed, one-third were from each province (33% n = 813 Badghis, 34% n = 840 Bamyan, 33% n = 824 Kandahar). Among those respondents who had delivered none of their children in a health center, money to pay for services appeared to be most important barrier to accessing institutional delivery (56%, n = 558). No transportation available was the second most widely cited reason (37%, n = 368), followed by family restrictions (n = 30%, n = 302). Respondents in Badghis reported the highest levels of barriers compared to the other two provinces. Respondents in Badghis were more likely to report familial or cultural constraints as the most important barrier to institutional delivery (43%) compared to Bamyan (2%) and Kandahar (12%) (p < 0.001). CONCLUSIONS: Despite the socio-demographic and geographic diversity of the three provinces under study, the top barriers to institutional delivery reported in all three areas are consistent with available evidence, namely, that distance, transport cost and transport availability are the main factors limiting institutional delivery. Proven and promising approaches to overcome these barriers to institutional delivery in Afghanistan should be explored and studied.

Nurses' uniform color and feelings/emotions in school-aged children receiving health care.

Children may fear nurses wearing white uniforms. When emotions and uniform color were studied in 233 children, many positive emotions were most often associated with blue, bold pink-patterned, or yellow-patterned tops (all p ≤ .002). Negative emotions were not associated with uniform top colors (all p < .001). However, after excluding "uniform color does not matter," 8 negative emotions were most often associated with white uniform color (p < .001-.04), and 2 others were most often associated with the yellow-patterned top. Bold pink-patterned and solid blue uniform tops were preferred. In conclusion, children's emotions were associated with nurse uniform color.

Depressive symptoms and AIDS-related mortality among a multisite cohort of HIV-positive women.

OBJECTIVES: We examined associations between depressive symptoms and AIDS-related mortality after controlling for antiretroviral therapy use, mental health treatment, medication adherence, substance abuse, clinical indicators, and demographic factors. METHODS: One thousand seven hundred sixteen HIV-seropositive women completed semiannual visits from 1994 through 2001 to clinics at 6 sites. Multivariate Cox and logistic regression analyses estimated time to AIDS-related death and depressive symptom severity. RESULTS: After we controlled for all other factors, AIDS-related deaths were more likely among women with chronic depressive symptoms, and symptoms were more severe among women in the terminal phase of their illness. Mental health service use was associated with reduced mortality. CONCLUSIONS: Treatment for depression is a critically important component of comprehensive care for HIV-seropositive women, especially those with end-stage disease.

Public policy and employment of people with disabilities: exploring new paradigms.

A "sea change" in public attitudes, legislation, and political power at the end of the 20th century in the United States has helped set the stage in the early 21st century for the entry of people with disabilities into the labor force. Major pieces of federal legislation have altered national policy with the intention of maximizing the work force participation of people with disabilities. At the same time, a new theoretical paradigm of disability has emerged, which emphasizes community inclusion, accommodation, and protection of civil rights. This "New Paradigm" of disability can be applied in concert with rigorous behavioral science methodologies to shed light on the outcomes of recent federal policy changes regarding the labor force participation of people with disabilities. In so doing, social science can be used in more meaningful ways to understand both the intended and unintended consequences of federal policy.

Effects of depressive symptoms and mental health quality of life on use of highly active antiretroviral therapy among HIV-seropositive women.

This study examines the effects of depressive symptoms and mental health quality of life on utilization of highly active antiretroviral therapy (HAART) among HIV-seropositive women. Data were collected biannually from 1996 through 1998 in a prospective cohort study. Women reported use of antiretroviral therapy, health and mental health status, demographics, and social and behavioral factors; CD4 count and viral load also were assessed. Random effects regression models estimated the longitudinal effects of depressive symptoms and mental health quality of life on the probability of HAART utilization, controlling for clinical indicators (CD4 count, viral load, symptom presence), demographics (race, age, education), behavioral factors (drug/alcohol use, clinical trials participation), service features (insurance status, mental health service utilization), and study site. High levels of depressive symptoms and poor mental health quality of life were found, and they significantly reduced the probability of HAART utilization. Receiving mental health services significantly increased the probability of utilizing HAART. HIV-seropositive women characterized as being in poor mental health were less likely to use HAART, whereas those receiving treatment of mental health difficulties were more likely to use HAART. These findings suggest that efforts to enhance women's access to psychological treatment may increase their use of the latest HIV therapies.

Use of highly active antiretroviral therapy in a cohort of HIV-seropositive women.

OBJECTIVES: This study examined longitudinal trends in use of highly active antiretroviral therapy (HAART) among a cohort of HIV-positive participants in the Women' Interagency HIV Study. METHODS: Beginning in 1994, 1690 HIV-positive women reported detailed information about their use of antiretroviral therapy at 6-month study visits. Multivariate logistic and Cox regression analyses were used to estimate the likelihood of antiretroviral therapy and HAART use among women with study visits preceding and following HAART availability. RESULTS: Before the availability of HAART, the cohort' likelihood of any antiretroviral therapy use was associated with clinical indicators (CD4 count, viral load, symptom presence) as well as behavioral factors (abstaining from drug and alcohol use, participating in clinical trials). After HAART became commercially available, newly emerging predictors included college education, private insurance, absence of injection drug use history, and not being African American. CONCLUSIONS: After the penetration of HAART into this cohort, additional differences emerged between HAART users and nonusers. These findings can inform public health efforts to enhance women' access to the most effective types of therapy.