Increasing global commitment to Universal Health Coverage (UHC) in the past decade has triggered UHC-inspired reforms and investments to expand health service coverage in many Low- and Middle-Income Countries (LMICs). UHC aims to ensure that all people can access quality health services, safeguard them from public health risks and impoverishment from out-of-pocket payments for healthcare when household members are sickThis paper reviews the role of health insurance as a policy tool to address health financing as a contributory mechanism for accelerating the achievement of UHC in LMICs. We focus on Nigeria's legal framework for health insurance coverage for its whole population and the role of technology in facilitating enrollment to health insurance schemes.From May to July 2022, we adopted a cross-sectional case study design combining: (i) a literature review of the effects of UHC with (ii) document analysis of health insurance systems in Nigeria, and (iii) secondary analysis of health insurance datasets to understand experiences of deploying MedStrat, a locally-developed digital health insurance management system, and its features that support the administration of health insurance schemes in multiple states of Nigeria. We drew on contemporary technology adoption models to triangulate diverse data analyzed from literature and documents reviews and from health insurance datasets to identify: (i) enablers of adoption of digital insurance schemes, (ii) the contribution of digital technology to expanding access to health insurance, and (iii) further scalability of digital insurance intervention.Preliminary findings suggests that digital insurance management systems can help to increase the number of enrollees for insurance especially among poor households. Three contextual enablers of adoption of digital insurance schemes were a favourable policy environment, public-private-partnerships, and sustained stakeholder engagement and training.via data encryption, maintaining audit trails for all data, and in-built fraud prevention processes. Our findings affirm that digital health technology can play a role in the attainment of UHC in LMICs.Key elements for successful scaling of digital health insurance schemes across Nigeria and similar contexts include: (i) ease of use, (ii) existing digital infrastructure to support electronic insurance systems, and (iii) trust manifested  Overall, health insurance schemes in LMICs have been found to improve access to health care as measured by increased utilization of health care facilities (32 out of 40 studies).”Increasing global commitment to Universal Health Coverage (UHC) in the past decade has triggered UHC-inspired reforms and investments to expand health services in many Low- and Middle- Income Countries (LMICs) . UHC meaAdditional to the above systematic review, country case studies have reported the effects of pursuing universal health insurance policies. For example, a Turkish study of the effects of universal health insurance for uninsured population groups (including low-income households and the unemployed), revealed that a non-contributory health insurance combined with a Green Card scheme  increaseIn 2015, Member States of the United Nations adopted the 2030 Agenda for Sustainable Development and its accompanying Sustainable Development Goals (SDGs), with the third goal of the agenda (SDG-3) aspiring to ensure good health and well-being for all. Member states also identified the achievement of UHC as the core target for assessing progress towards SDG-3.A recent multi-country cross-sectional study conducted by Ranabhat et al. 2018) using diverse data sources from 193 UN member countries  Regional Office for Africa developed a framework of actions for health systems strengthening towards UHC in the context of the SDGs in the region. The framework was later adopted by the 67th session of the Regional Committee for Africa in August 2017. According to a 2022 WHO assessment report titled Region, , the effThe objective of the service coverage index (SCI) of UHC is that people in need of essential health care services receive them, and that the services received are of sufficient quality to achieve potential health improvements. Over the past 20 years, all countries in the African region saw an increase in the UHC SCI, with nine countries exceeding the 25% benchmark. In general, the African region saw on average, an increase of 22 index points in health service coverage (from 24% in 2000 to 46% in 2019), which contributed to a gain of nine years of healthy life expectancy from 47.1 years to 56.1 years over the same period. High/upper middle-income countries had much higher UHC SCI and life expectancy at birth than lower-income countries. It is important to highlight although the sharp rise of nine years in life expectancy in the WHO African Region is greater than in any other region of the world during the 2000–2019 period, it is still well below the global average of 64 years. Over the same period, global healthy life expectancy increased by only five years.While the African Region had extended service coverage, no major increases in catastrophic health spending were seen over the past seven years . The report  suggestsIn the past two decades, the Federal Government of Nigeria (FGN) has implemented various financing mechanisms to stimulate utilization of services, improve the health status of citizens , and advAn appraisal in 2015 identified five challenges of the NHIS. First, the non-mandatory nature of contribution limited the scheme's capacity to mobilize resources . Second,However, despite implementation of social health insurance schemes by many state governments, a number of gaps remained regarding : (a) theTo address some of the above gaps, Nigeria's President Muhammadu Buhari signed the country's National Health Insurance Authority (NHIA) Bill 2022 into law on 19 May 2022  to regulThe NHIA visibly recognizes the relevance of Information and Communications Technology (ICT) in driving health insurance across all stakeholders as vividly captured in Section 3 Clauses l, v and w; and Section 13 Clause 6 of the NHIA Act. Digital health is contributing to the attainment of UHC, especially in Africa where many countries have deployed various degrees of automation of their healthcare and health insurance processes. In recent times, Nigeria , 23, GhaOgundeji et al.  identifiSimilarly, Shan et al.  pointed digital technology for supporting non-specialist health workers in the delivery of mental health care” in LMICs (including Nigeria).Much of the research on mobile health  systems in LMICs has been mainly in the areas of health worker training, health service delivery, disease tracking and in the management of chronic conditions such as mental health. Zayyad and Toycan , for exaSince 2020, the NHIA has embarked on a digital transformation initiative to transition its semi-manual operations into fully automated systems cutting across connectivity, biometric enrolment systems, beneficiary identification and card services, generation of credible healthcare industry analytics, as well as a unified stakeholder collaboration platform. However, despite the growing adoption of ICTs in driving health insurance systems in African and LMICs, none of the studies cited above focused on scaling health insurance systems technologies. To fill the gap in literature, our paper aims to report the experience of deploying MedStrat, a locally developed digital health insurance management system currently deployed in multiple states of Nigeria. A secondary objective is to explore the effect of digital technology in boosting enrollment to health insurance, and equitable access to and utilization of healthcare services by vulnerable groups. As expanding public health insurance is the gateway to increasing access to healthcare facilities and financial protection in many LMICs , this foFollowing the World Health Organization , this paThe country operates a three-level health system: primary, secondary, and tertiary, with healthcare provision being an overlapping responsibility of federal, state, and local governments . The Fedhttps://instratghs.com/) to develop and deploy a bespoke digital health insurance scheme  for help expand health insurance coverage particularly among poor and vulnerable populations of the three states.The study was undertaken in three states of Nigeria  that commissioned a local technology company, InStrat Global Health Solutions  services.Between May and July 2022, data collection for this cross-sectional study combined: (i) literature review of the effects of UHC—see the introductory section of this paper, with (ii) documents review of the evolution of health insurance systems in Nigeria, and (iii) secondary analysis of anonymized health insurance datasets obtained from the National and State Social Health Insurance Authorities. As this paper aimed to understand how digital technology shaped the adoption of health insurance by state governments, and enrollment of pregnant women for insurance in the three states, the documents reviewed as part of data collection for the study included: (i) state MCH policies, (ii) ICT policies, and (iii) reports of MCH programs to understand how the digital health insurance schemes were meant to work. The documents reviewed by the authors of this paper were used both as evidence for study findings  and as an explanation for the study findings .engaged, trained and motivated to implement a new initiative”, (3) the technology used needs to be simple and adaptable, (4) there should be alignment with broad policy goals to ensure sustainable funding, and (5) the overall ecosystem needs to enable the initiative . We used the above factors to develop a framework for building trust among users of digital technology  developed a digital insurance platform - the MedStrat Health Insurance System -, as a fully home-grown Health Insurance Management System (HIMS). This initiative was in response to a call by the Ondo State Ministry of Health, with whom InStrat had collaborated with for several years, for an HIMS that would digitize health insurance management activities and comply with Nigeria's Contributory Health Insurance Management Laws. The MedStrat HIMS fully automates all health insurance processes and supports paper-based back up where internet connectivity is insufficient or unavailable. The functionalities include electronic beneficiary enrollment, via a mobile application or the web portal management, health facility enrollment and management, electronic claims submission and processing; and real time reporting. MedStrat HIMS incorporates multi-step approvals for most processes to increase integrity and oversight of approval decisions. Approved services and drug lists and prices are maintained for all services including those for which prior authorizations are necessary. MedStrat integrates with all 3rd party payment gateways to process premiums electronically for Plan Types requiring premiums.To address inequitable access to MCH services in western Nigeria, and to accelerate achievement of UHC, in 2019, a local technology company, InStrat Global Health Solutions  schemes are contained in the system including medical, dental and laboratory services. Price lists are maintained for all services and medications covered by the SHI.3.Claims ManagementThe Provider Portal contains information about its current list of enrolled beneficiaries; patient encounter documentation; claims management processing, prior authorization request management; referrals management and reports and analytics.4.System AdministrationA high integrity claims management process is critical to the success of health insurance systems. The MedStrat HIMS system allows healthcare providers to complete Individual Claims Form (ICF) for patients after every encounter and submit to the Provider Portal for every Patient. At the end of the month, the HIMS system consolidates information from all ICFs submitted and automatically populate the Provider Claims Form (PCF). The healthcare Provider may also provide backup information that will support individual claims. The claim is reviewed through a multi-level process supported by an electronic workflow that allows for defined roles, system access levels and controls.via the Administration Portal which allows the following functions to be seamlessly performed by the SSHIA staff: Beneficiary Management; Provider Management; Referral Management; Staff Roles and Access Management; Third Party Agent Management; Management of Approved Services and prices including Laboratory and Medicine. The Administration Portal also maintains a real-time Activity Log that allows review or audits of all actions taken on the HIS.5.Customer CommunicationsThe HIMS is administered Beneficiaries: Outbound SMS messages upon enrollment confirmation, plan renewal or changes to assigned facility. Bulk SMS messaging is supported to all beneficiaries or different beneficiary groups .Healthcare Providers: Outbound SMS and email upon Provider enrollment confirmation; initiation/receipt of referral codes; claims approval, query or denial, initiation/receipt of prior authorization codes. Bulk SMS and emails can also be sent to all Providers or different groups .6.Reporting, Analytics and Data VisualizationMedStrat HIMS allows direct communication with clients and providers as follows:7.Training and Technical SupportWhile MedStrat HIMS maintains a reporting and data access portal, it is also linked to a robust 3rd Party Business Analytics web portal allowing visually appealing and user-friendly representation of real-time HIMS data including beneficiary enrollment details and statistics; Provider details, Claims and Financial information on Submitted Claims and Capitation Payments due.via online tutorials (available on InStrat's VTR Mobile Training Application), via a detailed instructions manual developed for each client  and via cheat sheets developed for important HIMS systems processes.8.Fraud and Abuse PreventionInStrat provides direct training and hands-on support to State Health Insurance Agency and third party agents. Supplementary training is also provided InStrat has built important fraud prevention technologies and processes into the HIMS to mitigate risk. At the system level the HIMS maintains a full audit-trail of all activities by anyone with access to the system and all data is encrypted while in transit, under processing or in storage.•The beneficiary ID format contains an important algorithm that prevents forgery and can be detected easily by any Provider or Agency staff.•All Individual Claims Forms can only be for patients whose coverage it verifies by their valid beneficiary enrollment number as patient information fields such as name, date of birth etc. are autofilled based on Beneficiary policy Number.•The covered services based on Plan type is autofilled based on Beneficiary policy Number and set to a maximum number of services. Submission of claims for services not on the approved list will be accepted by the system only if the Prior Authorization Approval Code is provided.•The MedStrat HIS will only accept Provider Claims Form (PCF) from authenticated providers.In addition, the HIMS provides the following:While the above eight pillars represent standard MedStrat HIMS functions, InStrat has collaborated with its clients to customize them to suit their schemes' requirements. Feature sets are customized for the numbers of, and differences in plan types, benefits, and administration of those benefits, claims adjudication and approval processes, and beneficiary and provider communications. Unique features are also developed to address unique use cases.The MedStrat HIMS is currently implemented in the following three states of Nigeria: Adamawa in the Northeast, and in Ogun and Ondo states in the southwest of Nigeria  to provide health insurance for all residents of the state. As mentioned earlier, the State Government commissioned InStrat to develop the MedSrat HIMS, which it adopted in December 2019 for administering health insurance to its population, currently estimated to be 4.7 million .Between 2019 and June 2022, a total of 37,946 people have benefitted from health insurance, 20,557 of which (or 54.2%) are pregnant women and children under age 5 funded through the State's equity fund named the Abiyamo Maternal / Child Health Insurance Scheme (AMCHIS), implemented at seven public hospitals in the state  was created on 27th of May 2019 after the successful passage of the Health Insurance Bill by the Ogun State House of Assembly which the state Governor signed into Law No: 039/2018. The Health Insurance Agency then adopted the MedSrat HMIS in May 2021 for administering health insurance for Ogun State's estimated population of 5.2 million . Since aThe Adamawa State Contributory Health Management Agency (ASCHMA) was established by the Adamawa State Law No:18 of 2018 to provide quality and affordable health care services to all citizens of Adamawa State whose population is estimated to be 4.3 million . The staBeing a novel use of technology to support a relatively new health insurance scheme, InStrat placed significant emphasis on building the capacity of all the State health insurance agencies to increase their understanding of the functions of the HIMS system and how to interact with it. The three levels of the training process were as follows:(1) The heads of the State Social Health Insurance Agencies and their core Agency ICT Staff were trained on all modules contained on the HIMS. This training was designed to allow the ICT staff to carry on the technical operation of the system. (2) All other departments that played roles in the health insurance scheme such as Accounts, Claims Processing, Human Resources were provided hands-on training on parts of the HIMS that affect their job functions.InStrat collaborated with core Agency staff to train healthcare providers, Third Party Administrators and Local Government Area focal persons on the modules of the health insurance system that were relevant to them.Designated InStrat technical officers and State Social Health Insurance Agency ICT staff conducted joint field visits to provide on-the-job training and monitoring support to health care providers and Third-Party Administrators (TPA) for up to three months after the initial training provided to ICT staff. After this, full responsibility for further training and ongoing support is transitioned to state insurance agency ICT personnel.via its proprietary Video Training (VTR) Mobile platforms for training frontline health workers. The VTR mobile training platform has been reported elsewhere 2.engaged, trained, motivated” Stakeholders must be “3.The HIMS must be useful to its users 4.The HIMS must be easy to use 5.The digital infrastructure needs to be in place to support the HIMS (Labrique)6.The HIMS needs to include elements that will build trust with users (TAM3)If we align Labrique, TAM, TAM2 and TAM3, we define a new framework for scaling HIMS in LMICs as follows:1.the provisions for digital transformation in relevant portions of the new NHIA law,2.adoption of functional HIMS platform by SSHIAs in Nigeria,3.increased digital technology awareness and acceptance within the health insurance eco-system,4.yearning for increased funding for health insurance digitization projects in Nigeria and other LMICs.Social health insurance in Nigeria is mostly financed through the Basic Healthcare Provision Fund from the Federal Government Annual Grant of not less than 1% of its consolidated revenue fund, as well as grants from international donor partners. State Governments have supplemented this funding with their own resources, especially for vulnerable populations  to transfer women who would have wanted to give birth at home to formal hospital settings to deliver their babies  were funded pulation . The equThe COVID-19 pandemic exacerbated the poor healthcare funding situation by compelling State Governments to redirect aspects of their health budgets to COVID-19 interventional efforts including setting up quarantine centers, COVID testing, sanitization zones at the expense of ICT-related investments. International donor partners have typically preferred to fund interventions for disease specific programs such as Malaria, HIV/AIDS and Tuberculosis. These disease-oriented funding mechanisms do not fully integrate digitization into their programing and they fail to recognize the umbrella role that health insurance schemes play in facilitating health care delivery and interventions across disease matrices.a)Favourable policy environment: Our analysis showed importance of the National Health Insurance Authority Act for obligatory nationwide adoption of digital health technology as a priority strategy for achieving the goals of increasing health insurance coverage and of accelerating the attainment of UHC (t of UHC . Similarb)Public private partnerships: The NHIA Act also promoted public-private-partnerships (PPP) in this case, between the national, state governments and technology companies for co-designing and deploying digital health insurance schemes for public benefit. Since 2013 when the NHIA embarked on aggressive fortification of the capacity of its ICT workforce, there have been no fewer than eighty (80) vendor proposals presented to the NHIA for digital health insurance implementations at different levels. While many of the digital proposals were general purpose health insurance computerized systems, others were specific to core health insurance operations particularly eClaims modules, patient encounter management systems, emergency services gateway, mobile health solutions for beneficiary access, enrolment systems, health insurance payment systems, health analytics tools, connectivity solutions optimized for health insurance stakeholders, as well as digital solutions for automating processes in Health Maintenance Organizations (HMOs).It is interesting to note that, of all vendors that ever proposed digital solutions to the NHIA, about 80% of vendors who submitted proposals to the NHIA usually claim to have existing national spread or possess the technical potential to offer nationwide insurance coverage devoid of geographic limitations. While these claims are largely unsubstantiated, it however portrays the enthusiasm of technology service providers that target health insurance with the goal to advance UHC.Implementing MedStrat HIMS across multiple states of Nigeria underlined three wider contextual enablers of scale-up of digital insurance schemes namely favourable policy environment, public-private-partnerships, and sustained stakeholder engagement.While the innovations offered by private service providers are commendable, the number and capability of these digital health insurance systems have continued to increase due to many reasons, including: (a) the growth in the stakeholder size in the Nigerian health insurance sector, (b) the influence of successful implementations such as the InStrat digital health solutions, (c) increased digital awareness due to COVID disruptions, as well as (d) the quest to use digital systems to foster compliance with emerging domestic and international regulations including the Health Insurance Portability and Accountability Act (HIPAA), the General Data Protection Regulation (GDPR), the Nigeria Data Protection Regulation (NDPR), NHIA Act, etc.c)Sustained stakeholder engagement: The PPP approach adopted in Nigeria boosted the feasibility of success for sharing resources, capabilities and project risks. In this case, InStrat Global Health Ltd provided the technological capability and digital health solutions while the Federal and State Governments provided healthcare infrastructure, ICT personnel for State Health Insurance Agencies and the population reach for ensuring successful digital health insurance projects.Goal 1 of ending poverty through reducing catastrophic household expenditure; Goal 3 of ensuring healthy lives and improving well-being though better health outcomes; and Goal 5 of achieving gender equality through increased insurance coverage for pregnant women; and Goal 10 of reducing inequality within and between countries though increased coverage of vulnerable people using health equity funds.We have demonstrated that the role of digital health insurance management systems in scaling health insurance coverage in LMICs cannot be relegated. The success stories amplified in our multistate case study corroborate the near-indispensability of ICT in the operationalization of health insurance in LMICs and Nigeria. A fully automated, well-functional health insurance management system underpins health insurance schemes’ effectiveness in channeling resources for health care delivery at scale, especially for poor and vulnerable populations. By utilizing findings from Labrique, TAM and TAM3 success factors for the adoption of technology, we developed a new framework for analyzing the scalability of HIMS. With substantial backing from the new NHIA law which made clear provisions for the mandatory application of ICT in the health insurance eco-system, we applied this new framework to LIMCs - specifically Nigeria in this instance. We conclude that the current MedStrat HIMS checks all of the boxes in the framework and therefore can easily scale. Therefore, if more funds are made available  to SSHIAThis paper has a number of limitations. First, it focuses only on Nigeria. There is no way to predict whether our findings are generalizable to other countries or contexts. Given the vast differences in the health insurance systems among countries, it is in fact likely that results elsewhere would differ. Research from other countries would provide valuable comparisons that would enhance the literature in this area.Second, given the stages of implementation of digital health insurance schemes in the three states, this case study involved the review of literature and insurance databases. It did not involve empirical data collection/analysis, nor did it interview programme stakeholders for their views. Interviewing or surveying stakeholders is an obvious avenue for future research.Third, the criterion for evaluation of positive impact of digital health interventions is based on a single vendor model. While this approach provides a credible basis for extrapolation from the three use case states, it also creates an opportunity for future adoption of a multi-vendor approach that can potentially confer stronger legitimacy to the claims, based on equity.


Xenopus laevis. The results are interpreted and integrated into programs of cell behaviors that account for the larval growth and histology, and metamorphic remodeling of each element. These programs provide a baseline for investigating hormone-mediated remodeling, cartilage regeneration, and intrinsic shape regulating mechanisms. These programs also contain four features not previously described in vertebrates: hypertrophied chondrocytes being rejuvenated by rapid cell cycling to a prechondrogenic size and shape; chondrocytes dividing and rearranging to reshape a cartilage; cartilage that lacks a perichondrium and grows at single-cell dimensions; and an adult cartilage forming de novo in the center of a resorbing larval one. Also, the unexpected superimposition of cell behaviors for shape change onto ones for larval growth and the unprecedented exploitation of very large and small cell sizes provide new directions for investigating the development and evolution of skeletal shape and metamorphic ontogenies.As the first and sometimes only skeletal tissue to appear, cartilage plays a fundamental role in the development and evolution of vertebrate body shapes. This is especially true for amphibians whose largely cartilaginous feeding skeleton exhibits unparalleled ontogenetic and phylogenetic diversification as a consequence of metamorphosis. Fully understanding the evolutionary history, evolvability and regenerative potential of cartilage requires in-depth analysis of how chondrocytes drive growth and shape change. This study is a cell-level description of the larval growth and postembryonic shape change of major cartilages of the feeding skeleton of a metamorphosing amphibian. Histology and immunohistochemistry are used to describe and quantify patterns and trends in chondrocyte size, shape, division, death, and arrangement, and in percent matrix from hatchling to froglet for the lower jaw, hyoid and branchial arch cartilages of  Cartilage precedes bone in both the development and evolution of vertebrate bodies. Cartilage and cartilage-like tissues are widespread in invertebrates , and carOur understanding of cartilage formation comes largely from mammals and birds, and from three foci of study: the embryonic origins of the cells that become cartilage , 14; theThis amniote-centered view of cartilage growth as highly regionalized and directional cell behaviors occurring in advance of bone replacement leaves unanswered several fundamental questions about how cartilage grows and evolves in the absence of endochondral replacement. How widespread are regionalized cell behaviors in nonamniotes, how does cartilage grow in the absence of endochondral replacement, and how is its shape regulated throughout life? More generally, how might the cell behaviors used in cartilage growth impact its histology and function, as well as its evolutionary potential or evolvability for shape change, and its capacity for regeneration?Amphibians are especially relevant because their feeding and breathing skeleton (viscerocranium) persists largely as cartilage and exhibits both simple and complex shapes that differ among species, grow with little or no shape change in larvae and adults, and undergo abrupt and radical shape changes during a midlife metamorphosis , 42, 43.Based on morphological and histological descriptions of cartilage growth and metamorphosis in frogs and salamanders, Rose , 12 propXenopus laevis from one day after hatching to one week past the end of metamorphosis. These three cartilages are particularly well suited for this analysis since they have distinct larval shapes, histologies, and functions in larval and postmetamorphic life, and their size and shape changes during larval and postmetamorphic growth and metamorphosis have been carefully documented in bivariate and multivariate analyses , 5142, 5Shape regulation in the viscerocranial cartilages studied here requires that many cell behaviors be coordinated throughout a large population of similarly differentiated cells and over long periods of time, large increments of growth, and changes in use. This regulation appears to involve mechanisms that are intrinsic to cartilage and separate from those controlling its morphogenesis. The lower jaw and ceratobranchial are able to correct for shape abnormalities that are induced in morphogenesis during their subsequent growth and shape change , 92. BioSeveral new phenomena described here might also have broader implications for research on cartilage repair, regeneration and structure. These include cartilage growth in the absence of perichondria, cell clusters arising and coalescing to form a new cartilage in the center of a resorbing one, and chondrocytes regulating their cell size and their surface contacts to form bifurcated and tapered, single cell-wide structures. The latter process is further regulated across a large field of similar structures to grow and maintain the complex surfaces required for feeding and respiration. As these processes are likely to be tractable only in whole tissues, they are prime candidates for spatial transcriptomics and proteomics , 99.Xenopus might help to develop cartilage repair treatments. Degenerative osteoarthritis involves abnormal chondrocyte proliferation leading to clonal cell clusters that expand at the expense of adjacent matrix [Additionally, both the lower jaw and ceratohyal exhibit what we call chondrocyte rejuvenation, wherein chondrocytes that have grown to relatively large sizes (~ 28 and 53 μm respectively) undergo either slow cell cycling with matrix secretion or rapid cycling without matrix secretion to return to a prechondrogenic size (~ 10 μm). For the sake of comparison, limb growth plate chondrocytes are typically 10–30 μm in greatest dimension , 36, 100t matrix . UnderstXenopus stands out in two respects: 1) the unexpected superimposition of cell behaviors for shape change onto ones for growth, and 2) the unprecedented exploitation of chondrocyte cell size to diversify cartilage shape, structure and histology.Understanding how cell behaviors accomplish cartilage growth and metamorphic remodeling is key to understanding the evolutionary origin and diversification of amphibian metamorphosis, and the evolvability of cartilage shape , 12, 101The superimposition of cell behaviors is evident in two ways. Peripheral chondrocytes in the ceratohyal complete two or more nuclear divisions in the 24 hours just before the region is lost to resorption , and braXenopus moves its jaw and ceratohyal almost continually to pump water through a relatively large tadpole mouth and very large branchial complex that functions in both food collection and gas exchange [Xenopus uses its hands to push food into its relatively small frog mouth, and its throat skeleton to breath air as other frogs do, but not to protrude and retract a tongue. The lower jaw program appears to use moderate chondrocyte growth and slow rejuvenation with matrix secretion to increase mechanical strength throughout growth and metamorphosis, and allow for a quick, moderate shape change that does not impede function. The ceratohyal program uses exceptional chondrocyte growth and rapid rejuvenation to produce a massive, but light larval element that can move a large volume of water efficiently, and be drastically transformed in shape, histology, and size. The branchial arch program exploits the ability of cartilage to grow at single-cell dimensions to evolve an exceptionally large, complex, and delicate filtering skeleton that compensates for the loss of gill filaments [The programs described here present a starting place for investigating differences in the evolvability of cartilage growth and shape change across vertebrates. This starting point, however, is a rather atypical amphibian with unusual functional needs , 12. As exchange –107. As ilaments , 109.Xenopus can be exploited for much greater ontogenetic divergence and for significant phylogenetic diversification is evidenced by the wide array of larval and adult shapes that have evolved in frog viscerocranial skeletons [That the cell behavior programs exhibited by keletons , 45. SomThis study is the first attempt to describe and quantify the cell features that underlie cartilage growth and shape change from early postembryogenesis to a juvenile stage for any vertebrate. The results are interpreted in terms of specific cell behaviors, which are integrated into programs to explain the larval growth and metamorphic shape change of three functionally important cranial cartilages. The results provide a conceptual framework and starting point for phylogenetic comparisons, and a baseline for investigating thyroid hormone-induced remodeling, and intrinsic shape regulating mechanisms involving cell communication, biomechanics and bioelectricity. They also reveal four phenomena not previously described in vertebrates: chondrocytes being rejuvenated after a lengthy growth period by dividing back to their prechondrogenic size and shape, a cranial cartilage that lacks a perichondrium and grows at single-cell dimensions, and chondrocytes dividing and rearranging to either reshape a fully differentiated cartilage, or form an altogether new cartilage in the midst of a resorbing larval one. More generally, the unexpected superimposition of cell behaviors for shape change onto ones for larval growth, and the unprecedented use of cell cycling to produce extremely large and small chondrocytes open up new directions for investigating the development and evolution of skeletal shape and metamorphic ontogenies.S1 FigXenopus tadpoles atypically lack gill filaments, the term is a misnomer for this species). (d) a dorsal view of the region outlined in c showing the vertical arrays of ornate processes in the wall of the basket (long arrows) and the large ornate processes around gill slits (short arrows). (e) a close-up of the part of the partition outlined in d showing adjacent rods (arrows) lined with ornate processes that become smaller dorsally towards their tips. Scale bars for a-c and d-e are 2 and 1 mm respectively. The branchial basket arises in embryogeny from four ceratobranchials laterally and two hypobranchials medially. The cartilages fuse to each other and extend dorsally to form walls and two partitions that enclose three flow chambers. Water enters a flow chamber from the mouth cavity, passes through filter surfaces and exits ventrally via the slit between ceratobranchial bases. The walls of the partitions and inner walls of the basket are lined by thin epithelia that define complex filter surfaces (a-b). The filter surfaces are raised as a result of many, small, polygonally shaped, closely spaced ornate processes of cartilage (or “arboresecent growths” [(a and b) anterior and posterior views into an E-cadherin-labeled basket at the levels of the otic (inner ear) capsule  and posterior edge of the eye . Long arrows in a-b indicate the epithelium-lined anterior and posterior filter surfaces of the first partition; short arrows indicate folds of dorsal epithelium; white arrows indicate mucus secreting columnar epithelium. (c) a ventral view of a dissected, alcian blue-stained basket showing the thickened ceratobranchials (cb1-4) that delimit the “gill” slits  that ligrowths”  for moregrowths”  for SEM growths” .(TIF)Click here for additional data file.S2 FigAll are resin-embedded, H&E-stained except b, which is BrdU-labeled, and hematoxylin counter-stained; a-d are frontal sections, and e-f are transverse. (a-c) the changes in cell size and arrangement that ceratohyal chondrocytes go through from their onset of chondrification at NF 43 (a) to the peak of larval cell cluster size at NF 64 (b), and to the emergence of new cell clusters at NF 66+ (c). The NF 64 cell clusters appear to be comprised of numerous, similarly sized chondrocytes that have appeared since NF 58 Click here for additional data file.S3 FigThis involved merging multiple 10 X phase photographs into a composite that captured an entire frontal or transverse section of the ceratohyal. (a) frontal and transverse sections for a left ceratohyal; the arrow shows the approximate level of the transverse section. Each composite was then used to create two images, an inverse, gray scale image of chondrocyte outlines (b) and one of white dots on a black background to indicate the locations of the cell nuclei within the chondrocytes (not shown). All cells had to be given a dot regardless of whether the nucleus was visible in the section. Any slide debris in the gray scale image was removed with Photoshop and any incomplete chondrocyte borders were closed to ensure that regions within the cartilage would be treated as separate cells. CellProfiler, which is free open source software , was use(TIF)Click here for additional data file.S1 Table(XLSX)Click here for additional data file.S2 Table(XLSX)Click here for additional data file.S3 Table(XLSX)Click here for additional data file.S4 Table(XLSX)Click here for additional data file.


Stress is a growing problem in the general population, but most especially for workers responding to the COVID-19 crisis. The present study examines stress and Burnout in Health Care workers and Emergency Responders during the third COVID wave in Italy. In addition, we explore the value of psychological Hardiness and positive coping strategies as protective factors against the ill-effects of stress.N = 220), Emergency Responders , volunteer Italian Red Cross workers (N = 328), and a comparison group (N = 400) drawn from the General Population of Italy.Over a 5-month period in 2021, surveys were administered across all Italian regions to several groups including Health Care workers (Results showed that among the groups, Health Care workers had the highest levels of Emergency Stress, while the Red Cross volunteers had relatively lower stress levels. Hardiness and positive coping levels were highest among Red Cross workers, and lowest in the General Population sample. The biggest impact on Burnout was seen among health care workers, especially on Emotional Exhaustion and Depersonalization. Multiple regression results showed that Hardiness operates as a moderator of the effects of Emergency Stress on Emotional Exhaustion and Depersonalization aspects of Burnout, while problem focused coping and Stopping Negative Thoughts-Emotions also showed moderating effects.These results suggest that Health Care workers and Emergency Responders would benefit from additional training in hardiness and positive coping skills. The confrontation with stressful events such as the COVID pandemic poses a threat to psychological health and wellbeing for the general population, but an even greater risk for Health Care workers who face added stressors related to the health emergency. Several studies have attempted to identify factors that provide resilience for Health Care workers in the COVID pandemic . In fact, the main hypothesis is that Health Care and Emergency Responders need a greater capacity for resilience and different coping strategies. The results obtained from this first study led to consider the group of the General Population too different to continue in subsequent analyzes to keep it together with Health Care and Emergency Responders.A second general hypothesis is that Volunteers Emergency Responders show different levels of Hardiness and positive coping from Health Care and professional Emergency Responders.The first study examined possible differences between the General Population and Health Care Workers (HCWs), as well as both professional Emergency Responders (ERs) and Volunteer Emergency Responders (VERs) in terms of coping and resilience skills. In the second study involving HCWs, ERs and VERs, the protective effects of Hardiness and coping strategies with respect to Burnout were evaluated, as well as their potential role as moderators in the stress—illness relation. As seen in previous studies  with a mean age of 31.95 . The General Population group included 312 females (78%) and 88 males.- N = 220 Health Care Workers (HCWs) with a mean age of 43.80  and included: 99 (45%) physicians and 121 (55%) nurses. Of the HCWs, 21.8% were males and 66.9% females. Of these, 60.5% were frontline workers dealing with COVID-19 patients.- N = 121 Emergency Responders (ERs) included firefighters, civil protection, and ambulance personnel, with a mean age of 47.53 . Of these, 53.7% were male and 46.3% female, and 54.5% were frontline workers with COVID-19 patients.- N = 328 Volunteer Emergency Responders of the Italian Red Cross (VERs) with a mean age of 47.0 . Of these, 40.2% were male and 59.8% female, with 50.9% of the VERs performing direct interventions on COVID-19 patients.- Any participant who treated COVID-19 patients directly was further classified as a “COVID patient.”Both studies used an online transactional survey, and participants were recruited from May to September 2021 from all Italian regions. The survey included online informed consent, several questionnaires and basic sociodemographic information. Participants' anonymity was maintained while collecting the data. All procedures used in both studies were approved by the Ethics Committee of the University of Urbino (Comitato Etico per la Sperimentazione Umana—CESU). The research was conducted in compliance with the ethical principles of research established in the “Declaration of Helsinki” and in the “Convention on Human Rights and Biomedicine” (Oviedo Convention).Some scales were administered to all participants of the four groups, such as those to measure Hardiness and coping strategies. Other scales were differentiated for the General Population. The HCWs, ERs and VERs received the same test battery, since both were directly involved in responding to the pandemic emergency; their measures included Emergency Stress and risk of developing Burnout from work-related stress.- The Hardiness Resilience Gauge (HRG) is a 28-item scale that measures total hardiness as well as the three hardiness facets of commitment, control and challenge  is a 10-item measure of perceived stress in life .To test for differences in coping strategies and Hardiness skills between the HCWs, ERs, VERs and General Population Groups, a one-way ANOVA was conducted with Bonferroni's To test for effects of hardiness and coping strategies in the General Population, a linear regression model was generated with PSS as the dependent variable, and age, gender, HRG and CSES-SF scales as predictors (Hy2).To test for the presence of higher levels of Emergency Stress and a higher risk of developing work-related stress problems in Health Care Workers and both Emergency Responders and Volunteers Emergency Responders, a one-way ANOVA was performed comparing the three groups (Hy3). To test for the protective effect of resilience capacities (HRG) and coping strategies (CSES-SF) on Burnout levels (MBI-HSS), Pearson correlations were first calculated to identify associations among the variables of interest, and then three distinct multiple regression models (H4) were generated.Finally, Hardiness and coping were investigated as potential moderators of the impact of Emergency Stress (ESQ) on Burnout, applying a series of OLS regression models including appropriate interaction terms (Hy5). Interaction effects are displayed graphically using procedures contained in the PROCESS macro (version 4.0) for SPSS Hayes, .t-tests to compare means, physicians and nurses were found not to differ on any of the variables except for Total ESQ scores, on which nurses showed higher stress levels . Thus, physicians and nurses were combined into a single Health Care Worker (HCW) group.Using post-hoc comparisons. These results are displayed in In addressing hypothesis 1, a series of one-way ANOVAs were conducted with Bonferroni's The highest Hardiness levels were seen in the Volunteer Emergency Responder (VER) group , and the lowest levels in the General Population (GP) sample . Similarly, the GP group showed the lowest levels of Problem Focused and Stopping Negative Thoughts-Emotions coping approaches, while Emergency Responders were comparatively high in these positive coping strategies. In terms of Support coping, the only difference observed was with Health Care Workers, show showed lower Support Seeking than Emergency Responders.R2 = 0.253; F = 16.279; p < 0.001) in PSS scores. Significant predictors were Hardiness Challenge , Problem Focused coping  and Stopping Negative Thoughts-Emotions  coping. Lower scores on all these predictors was associated with higher levels of reported stress. Younger age  and female gender  were also significant predictors, and thus appear to be risk factors for increased stress reactions in the General Population.To test for a protective role of HRG and CSES-SF scales on stress in the General Population sample, a linear regression model was generated, controlling for age and gender and predicting scores on the Perceived Stress Scale (PSS). The model was significant, explaining 25% of the variance , having managed COVID-19 patients, and HRG scales as predictors in step 1. Coping strategies were added in step 2.As can be seen in * HRG and for ESQ and each of the three coping scales. Since ESQ showed no effects on Burnout—Personal Accomplishment (PA), no models were tested for PA.Hypothesis 5 stipulates that Hardiness and positive coping strategies operate as moderators in the relation between Emergency Stress and Burnout. To test this, total HRG scores, coping strategies, ESQ  and Burnout scores were all standardized and entered into several univariate general linear models, along with interaction terms for ESQ * HRG predicting both of these Burnout components , and for ESQ * Stopping Negative Thoughts-Emotions predicting Burnout Emotional Exhaustion. Support Coping showed main effects predicting Burnout EE and D, but no interaction effects.Results  showed ss top of . AdditioIn order to visualize the interactions, significant effects were plotted using the PROCESS (v. 4.0) macro for SPSS Hayes, . As can In examining Hardiness and coping strategies, we found significant group differences as predicted. The resilience factors of Hardiness and positive coping approaches of focusing on the problem and Stopping Negative Thoughts-Emotions were higher in all three groups of COVID workers  compared to the General Population sample, lending support to Hypothesis 1. One possible explanation is that people who are high in Hardiness and positive coping skills are more attracted to Health Care and emergency service occupations in the first place. Also, the training and mutual support of coworkers and supervisors may play a role in reinforcing positive attitudes and coping skills in these workers James, . AnotherInterestingly, there were no differences between the General Population sample and the COVID worker groups in the coping strategy of finding social support, and all groups were relatively low on this dimension. This makes sense considering that social isolation and social distancing have been medically required in many areas in order to stop the spread of the COVID virus. At the same time, of the various groups examined, it is the Emergency Responders, both volunteer and professional, who report the highest levels of social support. For these workers then, support from coworkers, family and friends appears to be an important stress resistance resource. In contrast, Health Care Workers show significantly lower levels of support compared to Emergency Responders, reflecting their continuing social isolation throughout the pandemic even in the workplace. In this regard, many Health Care Workers have experienced increased social separation and communication difficulties as a result of special precautions and personal protective equipment such as face masks and hoods that must be constantly worn in the workplace. While medically necessary, these measures impose significant communication barriers between the health care workers and their patients, as well as their fellow health care providers.According to Labrague  Health CIn the present study, we included both professional Emergency Responders  as well as volunteers (Red Cross workers). Of all the COVID worker groups examined, the Volunteers showed the lowest levels of Burnout. The volunteer workers also showed the highest levels of Hardiness. Other studies have also found greater stress resilience in volunteer workers in high stress jobs. For example, in a study of officers assigned to assist grieving family members after a military death, those who volunteered for this sad duty showed fewer psychiatric symptoms and greater hardiness compared to officers who were ordered to do it . These results are in line with other research indicating that Health Care Workers around the world are being most severely affected by this global pandemic , with some different patterns for the Burnout components. Hardiness Commitment shows the largest (negative) effects with Burnout Emotional Exhaustion and Depersonalization. The strong sense of purpose and meaning that comes with Commitment thus appears to protect against these components of Burnout. In contrast, Hardiness Challenge and Control are more strongly (positively) linked to a sense of Personal Accomplishment. Hardiness Challenge entails a readiness to take on new and difficult tasks, as well as accepting disappointments and failures as opportunities to learn and improve. These results are in agreement with Bay and Novinrouz  that demFor Health Care Workers and Emergency Responders high in Hardiness Challenge, dealing with COVID patients and related problems is apparently a mission they feel is within their skills and capabilities to perform (Control), and an interesting if difficult Challenge to learn from. Problem Focused coping also enters into the model here, suggesting that these workers tend to take action to get things done and solve problems as they come up on the job. Also noteworthy in the regression results, the experience of direct exposure to COVID patients emerged as an additional independent risk factor for developing Burnout Emotional Exhaustion and Depersonalization. This may reflect the workers' ongoing fear of getting infected themselves, or of causing their family members to be infected. Also, their more frequent and close contact with seriously ill and dying COVID patients can lead to increased feelings of sadness and powerlessness.The coping approach of Stopping Negative Thoughts-Emotions appears to be valuable in protecting against the core Burnout element—Emotional Exhaustion. For workers involved in providing care and support for COVID patients, it is important that they not dwell on negative feelings and ideas as they perform their work. Those who are unable to block out disturbing images and thoughts, for example of sick and dying patients, may experience greater spillover of work into family life, as well as disrupted sleep and eating patterns. This finding is in line with results from a recent study of health care workers in 32 countries, in which maintaining positive thoughts was reported as an important coping mechanism for dealing with COVID related stress . Here, results were somewhat mixed, but overall as predicted. Hardiness is a significant moderator of Emergency Stress on Burnout Emotional Exhaustion and Depersonalization. This is in accord with many previous studies showing that hardiness is a buffer or protective factor in the relation of stress to symptoms and health . Health Care and Emergency Workers who are high in hardiness will tend to maintain their commitment and dedication to the work despite the difficulties, keeping their sense of purpose and control.Problem Focused coping also moderates Emergency Stress, but this time with the Depersonalization element of Burnout. Depersonalization or cynicism develops in workers as they become physically and emotionally exhausted, and experience increasing feelings of powerlessness to change the situation or make things better. They slowly become more and more alienated from the job and their coworkers, while also distancing themselves from an unfair system they feel powerless to change. According to our findings, Health Care Workers and Emergency Responders who routinely use Problem Focused coping strategies are more resistant to developing the depersonalization form of Burnout. Problem Focused coping also is quite strongly related to Hardiness in this sample , and so results may not be fully generalizable to Health Care Workers and Emergency Responders in other countries around the world. However, there is no This study has demonstrated that Health Care Workers and Emergency Responders are experiencing high levels of stress related to their COVID duties, which is leading to increased Burnout symptoms especially among the Health Care Workers. Volunteer Emergency Responders, as opposed to professionals, are somewhat less vulnerable. Most importantly, Hardiness and positive coping skills provide resistance to the ill-effects of work-related stress in these groups.While Hardiness and coping strategies are somewhat habitual or trait-like (showing stability over time and across situations), research has shown that specialized training programs can increase both hardiness (Bartone and Homish, The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.The studies involving human participants were reviewed and approved by Comitato Etico per la Sperimentazione Umana—CESU of the University of Urbino. The patients/participants provided their written informed consent to participate in this study.MV, TM, VG, DP, and PB: conceptualization, writing—original draft preparation, and writing—review and editing. MV, TM, and VG: methodology and investigation. MV, TM, and PB: formal analysis and data curation. MV and PB: visualization. MV, TM, DP, and PB: project administration. All authors contributed to the article and approved the submitted version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Health information systems strengthening interventions, such as the capacity-building and mentorship program used, leverages the expertise of stakeholders from multiple disciplines and can help improve data quality and information use at health facilities. As part of a collaborative capacity-building and mentorship program between 6 universities and the Ministry of Health, health facilities observed an improvement in the quality and use of health information system data across several tracer indicators.Establishing performance monitoring team meetings encouraged a data use culture for reviewing performance, identifying and solving problems, planning, and setting targets.Engaging a diverse group of experts from academia, regional health bureaus, and district health offices to build health worker capacity through training and mentorship was beneficial for improving the quality and use of health data.An academic-government collaborative capacity building and mentorship program is a promising approach to improving health information systems performance at the point of health care delivery. Building local ownership of the program, creating local mentors within the existing health system structure, and strengthening HIS expertise at universities are all essential for sustaining and expanding this model to other districts. Health information systems (HIS) performance in Ethiopia is currently insufficient, and improvements are required to ensure that decision making is data driven. We share our experiences from the early-stage implementation of a package of HIS capacity-strengthening interventions as part of an innovative academic-government collaboration that addresses challenges in HIS performance.We used routine program data to assess HIS performance using the Performance of Routine Information System Management (PRISM) assessment tools. The assessment employed a pre-post design and was conducted in a total of 24 selected health facilities  from 11 districts in Ethiopia at project baseline (2018) and midline (2020).Source document completeness rate reached less than 80% for the majority of the assessed data elements. Improvements were observed in quarterly report completeness (26% vs. 83%) and timeliness (17% vs. 48%). Though data inaccuracies are noted for all assessed data elements in 2020, the majority (83%) of skilled birth attendance and HIV reports (68%) fall within the acceptable range of reporting accuracy. The identification of performance-related problems, using performance monitoring team (PMT) meetings, improved between 2018 and 2020 (67% vs 89%). Similar improvements were also observed in developing action plans to solve identified problems via the PMT (52% in 2018 vs. 89% in 2020). Data use for planning and target setting (65% in 2018 vs. 90% in 2020), reviewing performance (58% in 2018 vs. 60% in 2020), and supervision (51% in 2018 vs. 53% in 2020) all improved among assessed health facilities.This study showed that a capacity-building and mentorship program that engages experts from multiple disciplines and sectors can improve the quality and use of health data. This partnership enabled engagement between government and academic stakeholders and allowed for a more robust exchange of resources and expertise toward HIS improvement. The strategy begins by evaluating and scoring facilities against a common set of criteria related to HIS structure and resources (30%), data quality (30%), and data use (40%). Facilities that score less than 65% are categorized as “emerging,” those between 65% and 90% are categorized as “candidate,” and those above 90% are accredited as a “model facility.” The grading process is followed by the development and implementation of action plans tailored to address identified barriers to data quality and use.Under the CBMP, local universities provide RHBs and ZHDs with opportunities to build their data quality and use capacities, following up with technical assistance.To support the MOH in addressing HIS challenges at a national scale, since 2016, the Ethiopia Data Use Partnership (DUP)—a consortium of technical partners committed to improving the collection and use of high-quality routine information in the health sector—has partnered with the MOH to advance the IR’s data use goals. The DUP supports HIS digitization, improves governance, enhances implementation research and knowledge management, and addresses other aspects of engendering a culture of health systems data use. DUP supports this work while stressing country leadership, ownership, and strong coordination among stakeholders from multiple disciplines and sectors. In partnership with 6 local universities, DUP is also supporting the implementation of the CBMP across Ethiopia.We provide experiences and lessons learned from the initial implementation of the CBMP at the health facility and district levels in Ethiopia to inform program improvements, optimize implementation of the IR agenda, and maximize its impact.The CBMP is currently being implemented in 187 public primary health centers and hospitals in 36 districts and 3 subcities located across all regions in Ethiopia. Under the CBMP, 6 universities  are supporting RHBs as they roll out a package of capacity-building interventions at district and facility levels. The package includes supportive supervision; on-site coaching and mentorship; training in data quality, analysis, visualization, and use; cross-site experience sharing; quality improvement initiatives, such as using performance monitoring teams (PMTs); and other activities designed to develop the skills and knowledge base of health workers and managers in data quality and information use. Interventions were adapted and tailored to each site based on ongoing monitoring via a routine (quarterly) needs assessment.The partnership with local universities also serves to progress organizational capacity building by linking academia to program implementation. University collaborators engaged in evidence generation and publication on themes related to the CWS implementation and, to date, have provided 81 Master’s and 8 PhD students the opportunity to conduct their theses on these topics. Moreover, the universities also conduct research within these sites to explore effective ways of implementing HIS interventions and improving HIS performance.A subset of 74 CBMP program sites were selected by DUP partners and RHB collaborators to become “learning and demonstration sites.” These sites received additional resources and more intensive capacity-building support to develop and implement site-specific HIS strengthening plans. They also received more frequent and structured mentorship visits  and on-site needs-based trainings focused on improving HIS capacity and competency among staff. As an initial step of a long-term strategy to diffuse learnings to other districts and health facilities across the regions, these sites served as incubation and testing locations for data use interventions.This study assesses the effect of the more intensive CBMP HIS intervention package implemented in the learning and demonstration sites on HIS performance at the primary facility level. We measured HIS performance at 24 learning and demonstration sites in 2018, then compared these indicators against the same measures at the same sites in 2020. The 24 sites  were randomly selected from the 74 CBMP learning and demonstration sites. The selected sites represent 1 district within each of the 11 regions in Ethiopia.The Performance of Routine Information System Management (PRISM) toolsThe data collection team received an intensive 5-day training, guided by a structured training manual, led by experts who were familiar with the Ethiopian health system and PRISM tools. Data were collected using tablets loaded with SurveyCTO, an Android-based mobile data collection platform, by data collectors who had experience in similar activities and were familiar with the Ethiopian health system. Internal data quality validation rules were programmed in SurveyCTO to minimize data collection errors. The data were uploaded in real time and managed on a cloud server. Regular data checks were administered throughout data collection to ensure quality.,In line with the World Health Organization’s (WHO) data quality assessment guideline, 7 tracer indicators were selected by the MOH to assess HIS data quality over a 3-month period in 2018 and 2020: (1) number of births attended by skilled birth attendant, (2) number of new and repeat contraceptive acceptors, (3) children younger than age 1 year who have received a third dose of the pentavalent vaccine (penta 3), (4) number of clients who tested positive for HIV, (5) number of children younger than age 5 years with pneumonia who received treatment (U5 pneumonia), (6) number of confirmed malaria cases using microscopy or rapid diagnostic testing, and (7) number of all forms of TB cases .11,13 ThData completenessSource document completeness (facility level): Number of facilities that completed primary source documents .Reporting completeness (district level): Number of expected reports compared to the number of reports actually submitted to the district health office.Reporting timeliness (district level): Number of facility reports received by the district health office by the predetermined deadline.Data accuracy: Numerical consistency between the data recorded in facility source documents and the data aggregated in monthly reports submitted to the district health office. Report accuracy was assessed among facilities providing services associated with the 7 tracer indicators  increased from 67.9% to 75.3% between 2018 and 2020. The proportion of health facilities with complete source documents increased from 2018 to 2020 across most tracer indicators: penta 3 (73% to 81%), contraceptive acceptors (67% to 87%), U5 pneumonia (58% to 83%), and TB (79% to 83%) .By 2020, HIS data quality improved in source document completeness, reporting completeness and timeliness, and reporting accuracy.Reporting completeness and timeliness for each report type that facilities were expected to submit  improved between 2018 and 2020 across all assessed report types . ImproveDuring the 2-year study period, the percentage of health facilities that fell within the acceptable data accuracy tolerance improved  for nearAll health facilities assessed in this study had PMTs established in 2018 . HoweverSimilarly, improvements at health facilities were observed in using routine data for planning, target setting, quality improvement, and service delivery performance review . The praAs ,The CBMP partnership has created opportunities for actors from disciplines previously excluded from HIS development to contribute to ongoing improvement efforts at district and facility levels. This program promotes HIS strengthening through implementing regular gap assessments and need-based training paired with mentorship and supportive supervision visits, regular review meetings, and experience-sharing and best practice dissemination. This program also focuses on applying implementation research to learn from and improve program activities. As echoed in the literature, focusing on these types of interventions leads to HIS performance improvement. Studies conducted in Ethiopia stress the importance of providing continual in-service data management training, supportive supervision, and feedback to health workers at the primary health care unit.The CBMP partnership has created opportunities for actors from disciplines previously excluded from HIS development to contribute to ongoing improvement efforts at district and facility levels.,,,For consistent information use to occur, data need to be of good quality so that users are confident that the data they consume are complete, accurate, and available in a timely manner.,,The study results show improvements in primary health care facilities reporting aggregated routine service and disease data to higher-level facilities. Following the nationwide transition from a fragmented electronic health management information system (HMIS) to a unified, web-based District Health Information System 2 (DHIS2), intensive trainings were provided to health workers on HMIS indicator definition, data capturing, and reporting.,We observed both positive and negative changes in the development of a data use culture during the 2-year study period. PMT meetings are one of the data use platforms institutionalized at district health offices and primary health care unit levels in Ethiopia. Findings from this study indicate that PMTs are generally used to promote the use of routine data to track performance, identify performance-related problems, and create action plans to address issues that arise. The importance of such review forums to strengthen HIS activities has been highlighted in other studies.Encouraging progress was observed during PMT meetings in the use of data for discussing and reviewing performance, problem identification, target setting, and planning.,This study also revealed improvements in data use for planning and target setting at health facilities. After 2 years of implementing activities under the CBMP, the use of routine health information for data presentation, root cause analysis, and action planning increased at the health facility level. This change was observed in the health facilities at the time of supervision and from success stories documented by some health facilities.,,A culture of supportive supervision is also necessary to promote data quality and support information use at all levels of the health system. This study acknowledges the inadequacy of HIS supportive supervision practices and use of data for supervision at the primary health care level. Supportive supervision practices must be enforced to ensure higher levels of data engagement and data quality across the health system. Strengthening existing supportive supervision  can contribute to improving health workers’ capabilities by encouraging their adherence to data quality assurance practices and use of data to address problems and service delivery issues.,,HIS data management and processes are also crucial to the production and use of quality data. The study revealed that some HIS processes, such as feedback loops and data visualization, are already in place at the health facility level. For managers to effectively apply facility data for the daily planning and management of primary health care delivery, the data must be processed into a meaningful format through analysis. However, results indicate that data analysis practices are weak at the health facility level. These findings are consistent with previous studies’ observations of the limited data analysis, interpretation, and problem-solving skills among health workers and how this, in turn, hinders information use at the point of care.The quarterly IR status assessment conducted by the university partners helped identify strengths and areas of improvement. Interventions were tailored based on the gaps in the assessment; behavioral interventions were also integrated, contributing to the improvements we observed. Moving forward, continual assessment and site-specific modifications are essential to further improve the effectiveness of the CBMP.These study findings underscore the importance of maintaining regular coordination and review meetings with CBMP partners, providing focused support to facilities and district health offices, and establishing mechanisms for routine HIS improvement monitoring. Furthermore, the findings suggest that mentorship decentralization, particularly by creating and using a pool of local mentors, could increase the impact and sustainability of HIS strengthening interventions.Our results should be interpreted with caution because of certain study limitations. These include the pre-post design, which lacks a control group, and the small sample size, which limits its statistical power and generalizability. While we acknowledge that our sample size is relatively small and only represents 1 district per region, sharing the results is crucial to imparting lessons learned from implementation. A more rigorous statistical evaluation of the CBMP, which will not be beset by this limitation, is forthcoming.This study showed that a program focused on building health worker capacity via training and mentorship, which engages a diverse group of experts from academia and staff from various levels of government, can improve the quality and use of health data. The CBMP partnership brought together untapped expertise from local universities to contribute to the national HIS improvement efforts. Linkages between academic and implementing institutions played an enormous role in in-service training, evidence generation through collaborative research, and capacity building. Expanding this model to other settings requires clearly defining intervention packages, building the HIS expertise of the universities, and fostering partnerships between academia and districts to create local mentors. This experience can be adapted to other health sector programs as well.


Cholera remains a major threat in sub-Saharan Africa (SSA), where some of the highest case-fatality rates are reported. Knowing in what months and where cholera tends to occur across the continent could aid in improving efforts to eliminate cholera as a public health concern. However, largely due to the absence of unified large-scale datasets, no continent-wide estimates exist. In this study, we aimed to estimate cholera seasonality across SSA and explore the correlation between hydroclimatic variables and cholera seasonality.Using the global cholera database of the Global Task Force on Cholera Control, we developed statistical models to synthesise data across spatial and temporal scales to infer the seasonality of excess (defined as incidence higher than the 2010–16 mean incidence rate) suspected cholera occurrence in SSA. We developed a Bayesian statistical model to infer the monthly risk of excess cholera at the first and second administrative levels. Seasonality patterns were then grouped into spatial clusters. Finally, we studied the association between seasonality estimates and hydroclimatic variables .vs eastern and southern Africa), which were composed of subregional clusters with varying degrees of seasonality. Exploratory association analysis found most consistent and positive correlations between cholera seasonality and precipitation and, to a lesser extent, between cholera seasonality and temperature and flooding.24 (71%) of the 34 countries studied had seasonal patterns of excess cholera risk, corresponding to approximately 86% of the SSA population. 12 (50%) of these 24 countries also had subnational differences in seasonality patterns, with strong differences in seasonality strength between regions. Seasonality patterns clustered into two macroregions (west Africa and the Sahel Widespread cholera seasonality in SSA offers opportunities for intervention planning. Further studies are needed to study the association between cholera and climate.US National Aeronautics and Space Administration Applied Sciences Program and the Bill & Melinda Gates Foundation. Vibrio cholerae bacteria of serogroup O1—still causes between 1 and 4 million cases per year.Despite being one of the oldest known infectious diseases, cholera—typically caused by toxigenic V cholerae in its natural brackish water habitats.Seasonality is one important aspect of cholera epidemiology, and cholera exhibits strong seasonal patterns in countries on the Bay of Bengal. The seasonal patterns of cholera in coastal and estuarine areas in this region have been linked in part to the ecology of Understanding seasonal variations in transmission of infectious diseases, such as cholera, has direct implications for improving surveillance systems and tailoring control and elimination efforts.Evidence before this studyVibrio cholerae O1 or O139, covering one or multiple countries in sub-Saharan Africa (SSA) for at least 2 years with reported cases. We identified 140 studies, of which 36 met our inclusion criteria. Of these, four were reviews, three were regional or global studies, and 29 focused on specific countries. Local-level seasonality studies were identified in Burundi (one), Côte d’Ivoire (one), Cameroon (two), Democratic Republic of the Congo (three), Ghana (one), Guinea-Bissau (one), Kenya (one), Mozambique (three), Nigeria (one), Senegal (one), Somalia (one), South Sudan (one), Togo (one), Tanzania (four), Uganda (two), South Africa (one), and Zambia (four). These local studies mainly consisted of epidemiological descriptions of cholera incidence at either the national or first administrative unit scale, covering between 2 years and 31 years of data. Most of these studies found seasonality in cholera incidence, with different patterns between countries. Two regional studies in west Africa found seasonal patterns in cholera incidence in the second part of the calendar year, with evidence for synchrony with rainfall patterns. Finally, one global study assessing the period of 1975–2005 found evidence for a latitudinal gradient of seasonality strength with weaker seasonality around the equator.We searched PubMed for previous studies on Nov 15, 2021, with no language or date restrictions using the search terms [“cholera*” AND “season*” AND ]. Two additional known articles not identified by our PubMed search were added, one on the seasonality of cholera in Kenya and one on the epidemiology of cholera in west Africa. Studies were included if they focused on the epidemiology of Added value of this studyAlthough most local-level and regional studies have found evidence for cholera seasonal patterns in SSA, gaps remain for some countries, and a continental-scale investigation is currently needed. By using a large database of cholera incidence, we evaluated and characterised cholera seasonality at a subnational scale in 34 countries of SSA for which sufficient data was available. We showed that cholera is seasonal in the majority of countries (24 [71%] of 34), with subnational heterogeneity in half of them (12 [50%] of 24). Our results enable the description of cholera seasonality at the continental level and the exploration of associations between cholera incidence and hydroclimatic variables.Implications of all the available evidenceThis work establishes the extent and strength of cholera seasonality in SSA, providing a basis on which to ground strategic decisions on large-scale intervention allocation, as well as future work on the climatic and non-climatic drivers of cholera seasonality in SSA.In this study, we aimed to develop an almanac of cholera seasonality across SSA, allowing for a subnational understanding of how cholera risk varies throughout the year. We then used these results to explore the correlation between hydroclimatic variables and seasonality across the continent.The cholera incidence data used in these analyses come from a large database curated by Johns Hopkins University on behalf of the Global Taskforce on Cholera Control (GTFCC). Data consist of suspected and confirmed cholera case reports from various ministries of health, WHO, Médecins Sans Frontières, ProMED, ReliefWeb, scientific literature, and publicly available epidemiological reports. Suspected-case definitions across counties and time periods do vary but are largely based on the recommended WHO and GTFCC case definitions.For our primary outcome variable, we defined a binary indicator of reported excess cholera occurrence, defined as above-average incidence. The indicator of excess cholera equals one when the monthly cholera incidence rate for a given administrative unit exceeds the 2010–16 estimated mean monthly incidence rate,We developed a modelling framework to infer the monthly relative risk of cholera occurrence at the administrative unit level, accounting for inter-annual variability and spatial dependence. We built upon a Bayesian model commonly used for areal count data, which consists of a logistic regression with random effects for the month of the year  and year, as well as a combination of spatially correlated and uncorrelated random effects at the administrative unit level with an intrinsic conditional autoregressive prior probability distribution.We considered a suite of different models that allowed for varying levels of flexibility in the seasonality of cholera within each country. First, we considered a model that has a single seasonal pattern per country, without assuming any shape . We then expanded this model to allow for two seasonal patterns within each country using a two-group mixture model with spatially auto-correlated grouping parameters. Within the mixture model, each administrative unit has a specific probability  of having one of two national seasonality patterns. We jointly estimated the two seasonality patterns and the mixture probabilities. We also extended these models to include inference on the start of the cholera year ,online.Data used in these analyses were not identifiable and this work was deemed to be non-human subjects research by the Johns Hopkins Bloomberg School of Public Health's institutional review board. Code, results, and a minimal dataset are available The funder had no role in the study design, data collection, data analysis, data interpretation, or writing of the report.Our analysis dataset included 236 741 records of cholera incidence from 34 countries in SSA between 1970 and 2021, spanning 2496 distinct second-level administrative units and 426 first-level administrative units  of 34 countries (86% of the SSA population) to support the hypothesis that excess cholera occurrence follows a distinct seasonal pattern .Code and analysis datasets consisting of monthly excess cholera, which are needed to reproduce the main findings, are available online (We declare no competing interests.


To study the effects of modified Lamaze breathing on abdominal pain experienced during colonoscopy. n = 40) and a control group (n = 45). Their basic clinical information was collected, and the bowel cleanliness, the time for the endoscope to reach the ileocecal junction, and the degree of abdominal pain of the two groups were compared.  Eighty-five patients who underwent common colonoscopy at our hospital between March 2021 and May 2021 were selected and randomly divided into the Lamaze group  was significantly lower in the Lamaze group compared with the control group.  Modified Lamaze breathing demonstrated promising effectiveness in reducing abdominal pain during colonoscopy and improving the quality of the examination. Colonoscopy, despite being a modern minimally invasive procedure with high accuracy in diagnosing colorectal diseases , may stiLamaze breathing originates from the “Lamaze method of childbirth,” first developed by French obstetrician Ferdinand Lamaze . It is aDuring a colonoscopy, the colon is stretched after a gas injection, which may cause pain and discomfort in the patients. The mechanisms of labor pain and colonoscopy-caused pain may be similar to a certain extent since the colon and uterus contain smooth muscles .In this study, we made patients undergoing colonoscopy to perform a modified Lamaze breathing technique and assessed its effects on the degree of abdominal pain to provide a new research direction for improving the quality of clinical enteroscopy.n = 40) and control group (n = 45). In the control group, routine nursing interventions for colonoscopy were performed, while for the Lamaze group, modified Lamaze breathing was performed in addition to routine nursing interventions.The data of 85 patients who underwent colonoscopy at the Digestive Endoscopy Center of our hospital between March 2021 and May 2021 were collected and randomly classified into the Lamaze group (Inclusion criteria of participants were as follows : (1) norThis technique was performed based on the following steps:Step A: thoracic breathing at the beginning of the examination: (1) complete relaxation; (2) staring at one point; (3) inhaling through the nostrils and exhaling through the mouth, with the abdomen relaxed; and (4) 6-9 times of inspiration and exhalation per minuteStep B: shallow and slow accelerated breathing when the colonoscopy passed through the descending sigmoid colon junction (mild pain): (1) complete relaxation; (2) staring at one point; (3) inhaling through the nostrils and exhaling through the mouth; and (4) accelerating breathing with increasing pain and slowing it down with decreasing painStep C: shallow breathing when the colonoscopy passed through the splenic flexure and hepatic flexure (pain above moderate degree): (1) complete relaxation; (2) staring at one point; (3) exhaling with a slightly opened mouth (emitting “hee hee” sounds), making noise from the larynx; (4) adjusting respiratory rate according to the intensity of pain, with the amount of air inhaled and exhaled kept the same to avoid hyperventilation; and (5) 4-6 continuous rapid breaths followed by forced exhalation. This step was repeated until the pain disappearedStep D: halitus movement when feeling pain but unable to gather strength: to open the mouth and breathe rapidly like gasping with the body relaxedAll examined patients took the same laxative for bowel preparation, and the quality of preparation was graded as follows: grade I, excellent with no visible feces; grade II, satisfactory with a small amount of visible feces, but did not block the visual field; and grade III, unsatisfactory with feces blocking the visual field and/or colonoscopy passage.After the colonoscopy, the patients' intraoperative pain was measured with the Wong-Baker faces pain rating scale . Patientt-test was used for comparison between the two groups and Wilcoxon rank-sum test for nonnormal distribution variables. Enumeration data were expressed as frequency (n) and percentage (%), and the chi-square test was used for statistical analysis. P < 0.05 was considered statistically significant.The SPSS 24.0 software was used for data analysis. Measurement data were expressed as mean ± standard deviation (SD), and the The general data of the patients included were analyzed. According to the results, there were no significant differences between the Lamaze group and control group in terms of gender, age, and history of colonoscopy , indicatBowel preparation was evaluated in both groups of patients during colonoscopy. The results showed that the intestinal tract of patients in both groups was clean without stool accumulation; there was no significant difference in bowel cleanliness between the two groups , indicatThe duration of colonoscopy was compared between the two groups. It was revealed that there was no significant difference in the time to reach the ileocecal junction between the two groups .The degree of abdominal pain caused during colonoscopy was compared between the two groups. The results showed that patients in the control group experienced significantly more intense pain in the anal region, descending sigmoid colon junction, splenic flexure, and hepatic flexure than those in the Lamaze group , suggestColonoscopy, as the main means of examination for colorectal diseases worldwide, is of great value for the early detection of colorectal lesions . HoweverThe pain arising from colonoscopy falls into the category of visceral pain, often caused by stimuli such as mechanical traction, intestinal smooth muscle spasm, ischemia, and inflammation, leading to unpleasant feelings accompanied by nausea, vomiting, and changes in cardiovascular and respiratory activities. As reported, to provide an effective field of view during colonoscopy, air injection is required to dilate the intestinal cavity, but excessive air can cause the intestinal lumen to be overinflated and stretched, stimulating nerve endings to produce pain. Since the colon is relatively free in the abdominal cavity, abdominal pain, abdominal distension, nausea, and vomiting can be triggered when the endoscope passes through bends such as the descending sigmoid colon junction, hepatic flexure, and splenic flexure. When the bowel is stimulated during colonoscopy, smooth muscle spasm of the bowel wall can occur, thus producing pain , similarIn this study, the pain-relieving effects of modified Lamaze breathing during colonoscopy were observed due to the advantages of Lamaze breathing and the characteristics of colonoscopy. The study results showed that there was no significant difference in age, gender, colonoscopy history, occurrence of complications, and time of the endoscope to reach the ileocecal junction between the two groups. Compared with routine nurse interventions for colonoscopy, Lamaze colonoscopy could significantly reduce the pain score of anal pain, descending sigmoid colon junction, splenic flexure, and hepatic flexure, which was consistent with findings of Yu et al. and T. Voiosu et al. , 21.Bowel cleanliness is also associated with the degree of abdominal pain in patients. Fecal water and bubbles in the enteric cavity can directly affect endoscopists' visual field, increasing the risk of missed diagnosis and treatment difficulties. Multiple repeated irrigation will increase the operation time and cause discomfort. Thus, poor intestinal cleanliness leads to more time for endoscopists to intubate, which could result in a higher rate of failure . HoweverPerforming modified Lamaze breathing preoperatively under proper guidance could subdue abdominal pain during colonoscopy, increase patients' tolerance, and enhance their experience during medical treatment.


Person-Centred Care (PCC) focuses on knowing the person behind the patient, engaging them as an active partner in their treatment, encouraging self-management and shared decisions. Inpatient multidisciplinary (MDT) clinics offer an opportunity for PCC by working collaboratively with service users (SU) in developing care plans. The aims of this project were to explore staff views and levels of satisfaction regarding the running of MDT clinics, to assess the quality and efficacy of changes made to MDT clinics, and to identify areas of practice which need improvement.In April 2021, MDT meetings of an acute inpatient clinical team were repurposed to 30-minute clinics with SU and relevant key professionals present, focusing on SU needs. Two staff surveys were completed in June and October 2021. Following the first survey, changes were made to the days clinics were run, attendance schedule, and staff allocation of responsibilities for efficient clinic running. In the second survey, a 14-question questionnaire was sent to all 48 staff members. The questions explored staff experience of MDT clinics. The measures were both qualitative and quantitative.The overall response rate was 31.25%, of which 40% by medical and 40% by nursing staff. Staff reported there was a positive impact in the collaborative development of care plans, including improved SU involvement, increased involvement of families, improved contribution from different professionals, and formulations providing greater insight. They reported improved task orientation, directed responsibility for task completion within the team, and enhanced role and responsibility of the named nurse. They thought there was less time for 1:1 work, but that the “overall benefits are worth it”. Improved relationship with SU was reported by 85%, increased engagement with SU care by 93%, and identifying clear goals for care plans by 93%. Nevertheless, problems with planning and logistics were reported by 77%. Main challenges included time management especially with external visitors or combination of remote and face-to-face attendees, relatively poor attendance of CMHT and family members, difficulties with informing and preparing SU ahead of their clinic times, number of attendees, and dissemination of MDT care plans.Repurposing MDT meetings to MDT clinics focusing on SU needs has a positive impact in inpatient clinical practice. MDT clinic planning and improving the involvement of community teams and family members can contribute to an optimal purposeful inpatient admission. Conducting inpatient MDT clinics can be a crucial part of working collaboratively with SU and PCC.