Learning in the district health system: How can meetings become spaces of reflection?

To fulfil its role, the District Health System (DHS) must enable and lead learning in the South African (SA) health system. Meetings are a core routine that can be leveraged to encourage learning in the DHS. In this article, we draw from existing experiences in SA to present practical steps that can be implemented to transform meetings into spaces of learning.

Ballistic impact response of a fluid/structure coupling-based modification of human thorax modelling.

Studying the mechanical response of the human thorax submitted to ballistic impact is a challenging field of research. For ethical reasons, it is not possible to perform tests on the human body. Numerical simulations are therefore one of the alternatives for evaluating the mechanical response of the human thorax. In earlier research, a simplified human thorax submitted to low-velocity impacts without ballistic protection was modelled. Not all internal organs in the thorax were taken into account. The only considered organs were the heart, lungs, trachea and aorta, with the space between them being void. The organs were covered by an idealised structure simulating the rib cage, spine and muscles. Such a simplified model was however sufficient in the field of less-lethal impact assessment. Indeed, in this case, only forces and displacements are taken into account. In the field of behind armour blunt trauma (BABT), spherical pressure or shock waves are expected to appear and propagate into internal organs. Nevertheless, the presence of the void space makes it impossible to evaluate the propagation of the considered waves. This paper focuses on a method for filling the void space and making the model more comprehensive. Starting from the initial meshed geometry of this simulated thorax, it uses a coupling between Lagrangian and arbitrary Lagrangian-Eulerian (ALE) objects. Finally, the use of the filled model is extended to a BABT case study. From the simulations, it could be concluded that BABT should be related to "blast" instead of "viscous" solicitations.

Experimental and numerical characterisation of rheological properties of a drop test response of a ballistic plastilina.

Plastilina is often used as a ballistic witness material (BWM) behind the armour to evaluate the backface signature (BFS). Indeed, it is cheap, reusable and it keeps its deformation after being impacted. Moreover, while it aims at evaluating the performance of ballistic protections when no perforation occurs, it can be subjected to a very wide range of strain/shear rates during a ballistic impact. Therefore, there is a need to improve the knowledge about the mechanical/rheological response of such a material. This paper proposes both experimental and modelling approaches to determine the response of the specific ballistic plastilina red Weible® over a wide range of shear/strain rate. A capillary rheometry analysis with control of temperature was performed up to 8.104 s-1. The corrections of Rabinowitsch and Bagley were applied and an attempt of the analysis of Mooney was considered. From the rheology of plasticine, a two-parameters based power-law constitutive equation was deduced. An experimental drop test was carried out using a specific standard setup. A high-speed camera was used for measuring the penetration depth of a steel ball into the plastilina. A numerical simulation of the drop test was performed by taking into account the mechanical properties of the plastilina. A good correlation was observed between the experimental and numerical results in terms of indentation depth evolution.

[The urgent need for a new ecosystem in healthcare]. / Nécessité d'un nouvel écosystème en santé Tous les éléments sont déjà disponibles.

The key performance indicators in healthcare illustrate that the system we run nowadays is no longer sustainable. There is an urgent need for fundamental changes within the current ecosystem, if we want to maintain or improve the levels of quality, security and equity in healthcare. Disruptive technologies profoundly modify all domains of our society. Those changes, driven by technical convergence, are particularly rapid and extensive in the fields such as big data and analysis, artificial intelligence, cloud and blockchain. These continuously evolving technologies could potentially offer opportunities to efficient problem solving in the health care sector. The culture of our organizations needs major changes and especially adaptability and fast speed integration to a process which is inevitable.

Les indicateurs clés en matière de santé démontrent que le système de santé que nous connaissons aujourd'hui n'est pas financièrement durable. Dès lors, des changements fondamentaux s'imposent si nous voulons maintenir ou améliorer la qualité, la sécurité et l'équité au niveau des soins de santé. Les technologies nouvelles, souvent taxées de «disruptives¼, modifient profondément la société civile. Il s'agit essentiellement de développements en matière de «big data¼, l'intelligence artificielle, le «cloud¼ et le «blockchain¼. Ces nouvelles technologies, déjà éprouvées dans d'autres domaines d'activité, pourraient bien apporter des solutions pour les problèmes auxquels nous sommes et serons immanquablement confrontés dans le domaine de la santé. Il faudra adapter ces nouvelles techniques aux besoins des bénéficiaires et des utilisateurs, mais également veiller à un changement rapide de la culture de nos organisations afin qu'elles intègrent plus rapidement et facilement ces changements.

Mapping the existing body of health policy implementation research in lower income settings: what is covered and what are the gaps?

This article uses 85 peer-reviewed articles published between 1994 and 2009 to characterize and synthesize aspects of the health policy analysis literature focusing on policy implementation in low- and middle-income countries (LMICs). It seeks to contribute, first, to strengthening the field of LMIC health policy analysis by highlighting gaps in the literature and generating ideas for a future research agenda and, second, to thinking about the value and applicability of qualitative synthesis approaches to the health policy analysis field. Overall, the article considers the disciplinary perspectives from which LMIC health policy implementation is studied and the extent to which the focus is on systems or programme issues. It then works with the more specific themes of the key thrusts of the reviewed articles, the implementation outcomes studied, implementation improvement recommendations made and the theories used in the reviewed articles. With respect to these more specific themes, the article includes explorations of patterns within the themes themselves, the contributions of specific disciplinary perspectives and differences between systems and programme articles. It concludes, among other things, that the literature remains small, fragmented, of limited depth and quite diverse, reflecting a wide spectrum of health system dimensions studied and many different suggestions for improving policy implementation. However, a range of issues beyond traditional 'hardware' health system concerns, such as funding and organizational structure, are understood to influence policy implementation, including many 'software' issues such as the understandings of policy actors and the need for better communication and actor relationships. Looking to the future, there is a need, given the fragmentation in the literature, to consolidate the existing body of work where possible and, given the often broad nature of the work and its limited depth, to draw more explicitly on theoretical frames and concepts to deepen work by sharpening and focusing concerns and questions.

Chemical communication of predation risk in zebrafish does not depend on cortisol increase.

We investigated chemical cues among groups of zebrafish (Danio rerio) when communicating information about the risk of predation. We found that visual cues of the predator (tiger Oscar, Astronotus ocellatus) did not increase whole-body cortisol levels in groups of zebrafish but that water conditioned by these (donor) zebrafish stressed (target) conspecifics, thereby increasing whole-body cortisol. This finding was confirmed when these zebrafish groups were in different aquaria and communicated exclusively via water transfer. This result indicates that the stress induced in the target zebrafish does not depend on an increase in whole-body cortisol levels in the donor zebrafish. Because cortisol participation is rejected in this predation-risk communication, other chemicals from the stress systems should be investigated.

Eye darkening as a reliable, easy and inexpensive indicator of stress in fish.

We expand the use of eye darkening (ED) to indicate non-social stress in the fish Nile tilapia Oreochromis niloticus (L.). ED is easily estimated, not requiring any sophisticated equipment, and is non-invasive, facilitating the collection of several measures of stress over time. In the current study, we showed the following: (i) high- and low-ED occur spontaneously, indicating different fish reactions to adjustments to a novel environment; (ii) fish confinement or air exposure clearly increases ED (air exposure is a stronger stressor than confinement), and the time to restore basal values indicates the severity of the impact of the stressor on the fish (this response is not affected by period of the day, e.g., morning or afternoon); and (iii) in adults, females were more responsive (slower recovery) to 2-min air exposure than to 30-min confinement.

Red light stimulates feeding motivation in fish but does not improve growth.

Nile tilapia fish were individually reared under similar light levels for 8 weeks under five colored light spectra (maximum wavelength absorbance): white (full light spectrum), blue (∼452 nm), green (∼516 nm), yellow (∼520 nm) or red (∼628 nm). The effects of light on feeding, latency to begin feeding, growth and feed conversion were measured during the last 4 weeks of the study (i.e., after acclimation). We found that red light stimulates feeding, as in humans, most likely by affecting central control centers, but the extra feeding is not converted into growth.

A case study: the effect of visitors on two captive pumas with respect to the time of the day.

This study analyzed the effects of noise levels and number of visitors on the behaviors of a mother puma and her daughter in a zoo environment with respect to the time of day. The study monitored visitation (noise and number) over two 1-week periods (4 weeks between periods) and frequency of various puma behaviors (videorecorded). The study analyzed videotaped behavior of the pumas based on the time of day and visitors' number and noise levels. There was a direct association of puma behaviors with visitors' number and noise levels. The daughter puma was the most affected and behavioral changes of both pumas correlated more strongly with the noise level than the number of visitors. The noise level and number of visitors affected the behavior of the mother and her daughter only in the morning. The results of this study indicate that both noise level and number of visitors affected these pumas but revealed the noise as predominant. Moreover, the response of these pumas to visitors depended on the time of the day.

New vaccine adoption: qualitative study of national decision-making processes in seven low- and middle-income countries.

As more new and improved vaccines become available, decisions on which to adopt into routine programmes become more frequent and complex. This qualitative study aimed to explore processes of national decision-making around new vaccine adoption and to understand the factors affecting these decisions. Ninety-five key informant interviews were conducted in seven low- and middle-income countries: Bangladesh, Cameroon, Ethiopia, Guatemala, Kenya, Mali and South Africa. Framework analysis was used to explore issues both within and between countries. The underlying driver for adoption decisions in GAVI-eligible countries was the desire to seize GAVI windows of opportunity for funding. By contrast, in South Africa and Guatemala, non-GAVI-eligible countries, the decision-making process was more rooted in internal and political dynamics. Decisions to adopt new vaccines are, by nature, political. The main drivers influencing decisions were the availability of funding, political prioritization of vaccination or the vaccine-preventable disease and the burden of disease. Other factors, such as financial sustainability and feasibility of introduction, were not as influential. Although GAVI procedures have established more formality in decision-making, they did not always result in consideration of all relevant factors. As familiarity with GAVI procedures increased, questioning by decision-makers about whether a country should apply for funding appeared to have diminished. This is one of the first studies to empirically investigate national processes of new vaccine adoption decision-making using rigorous methods. Our findings show that previous decision-making frameworks (developed to guide or study national decision-making) bore little resemblance to real-life decisions, which were dominated by domestic politics. Understanding the realities of vaccine policy decision-making is critical for developing strategies to encourage improved evidence-informed decision-making about new vaccine adoptions. The potential for international initiatives to encourage evidence-informed decision-making should be realised, not assumed.

Ventilation rates indicate stress-coping styles in Nile tilapia.

Behavioural responses to stress can form distinct profiles in a wide range of animals: proactive and reactive profiles or coping styles. Stress responsiveness can also differentiate between the behavioural profiles. The tendency to regain feed intake following transfer to a novel social-isolation tank (the speed of acclimation) can discriminate between proactive or reactive profiles. Consequently, differential stress responsiveness can be linked to this feeding behaviour trait. This study shows that ventilation rates of Nile tilapia, Oreochromis niloticus (L.), correlate with the rate of feeding resumption, following transfer to a novel social-isolation aquarium. Therefore, ventilation rate (VR) indicates coping styles; consequently, VR is a proxy for the way fish will deal with environmental challenges.

The correlation between subordinate fish eye colour and received attacks: a negative social feedback mechanism for the reduction of aggression during the formation of dominance hierarchies.

Eye darkening has been linked to social status in fish. The subordinate's eyes darken, while the eyes of the dominant fish become pale. Although this phenomenon has been described in salmonid fishes and in the African cichlid Nile tilapia Oreochromis niloticus, it is unclear whether eye darkening correlates with a reduction in aggressive behaviour. Thus, we evaluated the link between social status and eye darkening. We evaluated whether the eye colours of subordinate fish correlate with the frequency of received attacks in a neotropical fish, the pearl cichlid Geophagus brasiliensis. We paired pearl cichlids and quantified both the aggressive behaviour and the eye darkening of each fish. As has been described for Nile tilapia and Atlantic salmon, a clear-cut hierarchical relationship formed, where dominance and subordination were associated with pale and dark eye colours, respectively. Initially, eye colour darkening was positively correlated with the frequency of received attacks; however, a negative association occurred following eye darkening, in which the intensity of aggressive interactions decreased. Thus, fish that initially received a high number of attacks signalled subordination more rapidly and intensely (rapid and dramatic eye darkening), thereby inducing a negative social feedback mechanism that led to reduced aggression.

The aggressive behavior of Nile tilapia introduced into novel environments with variation in enrichment.

Many studies show environmental enrichment is correlated with benefits to captive animals; however, one should not always assume this positive relationship given that enrichment increases the amount of resources that a territorial animal must defend and possibly affects its aggressive dynamics. In this study, we tested if environmental enrichment affects aggressive interactions in the aggressive fish Nile tilapia (Oreochromis niloticus). We compared fights staged between pairs of male tilapia of similar size (= matched in resource holding potential) in a novel arena that was either barren or enriched, to examine whether enrichment enhances territory value in line with theoretical predictions, with the potential for compromised welfare. We evaluated time elapsed until the first attack (latency), frequency of aggressive interactions and fight duration. We detected fight dynamic differences at the pair level. Higher resource value generated increased aggression but had no effect on fight duration or latency. This conclusion is in line with game theory predictions concerning resource value and contradicts the theory that enrichment of the environment will serve welfare purposes.

Challenges in assessing fish welfare.

Descriptions of feeling states in nonhuman animals have relied on indirect evidence from empirical data. Assumptions that fish do not experience suffering lack evidence and in fact contradict a large body of indirect scientific evidence and ethical concern. Why should the burden of proof rest on those defending the hypothesis that fish feel pain and other discomfort? In this article I address this controversy and describe typical methodsand the problems associated with themto identify animal welfare (feeling-based, physiological, and behavioral approaches intended to demonstrate feelings and welfare states). Then I urge a shift in scientific focus from efforts to either identify an internal state of well-being or determine whether an organism suffers, to efforts to identify conditions that promote a "good state" for an animal (i.e., a state it would choose). For this approach, I discuss preference tests and their implications for scientific research, teaching, aquarism, and fishing.

Health systems and the implementation of disease programmes: case studies from South Africa.

This paper analyses the transfer and implementation of two internationally formulated infectious disease strategies in South Africa, namely, directly observed therapy (DOTS) for TB and syndromic management (SM) for sexually transmitted infections (STIs). Using the tools of policy analysis, this paper seeks to draw conclusions from contrasting experiences with the two strategies. DOTS and SM differ with respect to styles of engagement by World Health Organization (WHO), the international agency promoting the ideas, in the following ways: continuity and networking between policy makers, practitioners and researchers nationally; and approaches to sub-national implementation. We show how these factors may have been important to national uptake, and conclude on the need for a context sensitive approach to policy transfer and a balance between bottom-up and top-down implementation strategies. These insights may have relevance for the current global wave of treatment programmes for HIV and other infectious diseases.

Geographic patterns of deprivation in South Africa: informing health equity analyses and public resource allocation strategies.

There is a growing interest in the use of small area analyses in investigating the relationship between socioeconomic status and health, and in informing resource allocation decision-making. However, few such studies have been undertaken in low- and middle-income countries (LMICs). This paper reports on such a study undertaken in South Africa. It both looked at the feasibility of developing a broad-based area deprivation index in a data scarce context and considered the implications of such an index for geographic resource allocations. Despite certain data problems, it was possible to construct and compare three different indices: a general index of deprivation (GID), compiled from census data using principal component analysis; a policy-perspective index of deprivation (PID), based on groups identified as priorities within policy documents; and a single indicator of deprivation (SID), selected for relevance and feasibility of use. The findings demonstrate clearly that in South Africa deprivation is multi-faceted, is concentrated in specific areas within the country and is correlated with ill-health. However, the formula currently used by the National Treasury to allocate resources between geographic areas, biases these allocations towards less deprived areas within the country. The inclusion of the GID within this formula would dramatically alter allocations towards those areas suffering from human development deficits. The area in which analysis was undertaken was not, however, sufficiently small to identify pockets of deprivation within the less deprived metropolitan areas. These findings suggest that it is feasible to conduct small area analyses in LMICs but that specific attention needs to be given to the size of the geographic unit used in analysis. In addition, they highlight the importance of considering deprivation in resource allocation mechanisms if vertical equity goals are to be promoted through resource allocation, particularly within decentralized health systems.