Odocoileus virginianus) are believed to be a self-sustaining reservoir for bovine tuberculosis (bTB) in northeastern Lower Michigan, USA. Although a comprehensive control program is in place and on-farm mitigation strategies to curtail bTB transmission between cattle and deer have been implemented for over a decade, cattle and deer continue to become infected with the disease. Thus, renewed motivation to eradicate bTB is needed if that is truly the goal. Recurrent detection of bTB in cattle in the region is of mounting concern for state and federal agricultural agencies, producers, and wildlife managers. Current on-farm mitigation efforts include fencing and refined cattle feeding and watering practices. Liberal removal of antlerless deer through hunter harvest and disease control permits (DCPs) issued to cattle producers and agency sharp shooters have also been ongoing. Although these strategies have merit and efforts to reduce prevalence in deer and occurrence of positive farms are elevated, additional actions are needed. Heightened management actions to combat bTB in deer could include deer vaccination programs, strategic habitat manipulations to redistribute deer from farms, and precision removal of deer in proximity to high-risk farms. Foundational research to address development and delivery of vaccine to free-ranging deer is complete. Strategic management and habitat manipulation could reduce and disperse local concentrations of deer while better meeting wildlife, forestry, and agricultural goals. The responses of local deer populations to targeted removal of individuals are generally understood and there is potential to reduce deer activity around agricultural operations while allowing them to persist nearby on natural foods. We summarize the history and progress to date, discuss the realized merit of novel management strategies, and suggest options to rid deer and cattle in Michigan of bTB.Free-ranging white-tailed deer ( Integrated disease management: employing a variety of proven strategies simultaneously to most efficiently achieve management objectives.Mitigation measures to protect cattle: specific actions taken to reduce potential for direct and indirect transmission of M. bovis from wildlife to cattle.Management strategies for deer: specific actions designed to reduce potential for maintaining disease within free-ranging deer such as using hunters or professional sharpshooters to reduce deer numbers and eliminating the provisioning of anthropogenic food sources with the intent of attracting and maintaining deer concentrations.Negative impacts of supplemental feeding and baiting: anthropogenic feeding leads to artificially high and concentrated populations of wildlife which in turn increases disease transmission risk and prevalence.Setting realistic goals: developing a documented and well-informed formal strategy designed to reach a common and achievable goal.Public support, political will: varying stakeholder motivations must be considered, reconciled and presented to decision makers so they can empower the pursuit of common goals.Mycobacterium bovis (M. bovis) bacterium was historically a disease among cattle that spilled over into free-ranging wildlife where it persists (Bison bison) to 5 with an unknown or ≥ 0.5% herd prevalence. The 5 levels include: (1) Accredited-free zone (“TB free”), (2) Modified accredited advanced zone (MAAZ), (3) Modified accredited zone (MAZ), (4) Accredited preparatory zone, and (5) Non-accredited zone. Zoning enables agencies to tailor surveillance and management strategies relative to regional disease prevalence and potential risk of spread (Bovine tuberculosis (bTB), caused by the persists –3. Bovine (MAZ),  AccreditMovement of cattle from the MAZ must originate from a bTB accredited-free herd or one that has had a negative whole herd test within the previous 12 months and requires a movement certificate, unless the cattle are being moved directly to slaughter. On March 21, 2018 a new TB Zoning Order was signed into effect by the Michigan Department of Agriculture and Rural Development (MDARD) that established the Enhanced Wildlife Biosecurity Area  452 in the center of the MAZ) . DevelopIn 1975 and again in 1994 bTB was detected in white-tailed deer in the northeastern lower peninsula (NELP) of Michigan. After which the Michigan Departments of Natural Resources (MDNR) initiated a surveillance program of testing hunter-harvested deer –10 Figu. A collaM. bovis bacterium were disseminated into the spill-over host, deer, which now spill the pathogen back over to cattle . Lik. LikM. b2) and there were high densities maintained largely through supplemental feeding by hunters and other deer enthusiasts  implementation of management strategies to reduce prevalence in host species including wildlife and livestock; (3) establishment of well-defined goals, plans and policies; and (4) initiation of strategies to build and maintain support of the broad array of stakeholders.Approaches to eradicating disease are situational dependent though often include common key components. Components of previous eradication strategies include: (1) implementation of mitigation measures to protect against transmission of M. bovis between deer and cattle on their properties , traditionally developed and used for reducing the killing of livestock by predators, have also proven effective in keeping deer from directly and indirectly coming in contact with cattle . Using sneficial , 44. Altneficial , 44.M. bovis  tags became a requirement for Michigan producers in the endemic area to move live cattle off their farms in 2007. These requirements enable trace-back investigations to locate where and when bTB-infected cattle shared the same space as other cattle, with the goal of identifying other potentially infected animals and premises , 37, 47.Population reductions are often considered or used in response to outbreak of disease and involves reducing the density of the host population through strategic lethal removals, usually through culling by professional sharpshooters, or increased recreational hunter harvest , 51. LarM. bovis between deer and cattle the MDNR initiated a program in 1998 in which cattle producers could acquire DCPs allowing them to personally address the deer situation on their land by harvesting deer themselves or enlisting the help of sharpshooters with the USDA Wildlife Services   . Despiteed/year) . Each ased/year) .All existing 130 commercial cattle producers in the EWB Area require a deer removal component that enables sharpshooters to remove deer from in and around farms and pastures. For example, in Dressel's  study upWildlife management consists of three components: (1) the biota or populations, (2) the habitats or ecosystems organisms need to persist, and (3) the people or stakeholders that live in the ecosystems and interact with the wildlife resource . To dateThe Alpena-Montmorency Conservation District of Michigan has recently initiated a cost-share program that may assist in influencing deer movement patterns, potentially away from stored feed, water sources and livestock concentrations, by initiating habitat improvements for deer through forest management activities. This new program, if implemented strategically could stimulate deer to redistribute themselves away from agricultural areas to other, naturally occurring vegetation types. The program also includes incentives that encourage data collection and the liberal harvest of antlerless deer .The quality and distribution of a species' habitat is a primary driver influencing the spatial and temporal distribution of species , includThe core of the bTB area, DMU452 is composed primarily of private land (93%)  that is M. bovis, (3) reducing crop damage, and (4) meeting economic objectives of landowners for harvesting forest types. Such a habitat-based bTB management and research approach could be initiated and simultaneously integrated with other bTB mitigation practices. The successful management of this complex problem could be enhanced if the habitat for deer were factored into the management equation.Habitat management on public lands is a primary activity used by agencies to meet wildlife management objectives and satisfy a diversity of stakeholders, yet it is poorly understood how frequently or what types of management, if any, occur across private lands. The use of landowner incentive or cost-share programs to manipulate forest cover types to improve habitat conditions away from agricultural lands and livestock operations should be investigated for their efficacy in: (1) providing quality habitat, (2) shifting the distribution of deer away from agricultural areas at high risk for transmission of Original actions to eradicate bTB in Michigan combined with recently emerging science-based strategies have all been insufficient to date, primarily due to waning stakeholder support. Several new strategies and directions are mentioned above and have begun, here we discuss additional potential measures to consider if the collective desire of agencies, stakeholders, and other publics is to eradicate bTB from Michigan.As stated by Riley et al. , “An assMost >90%) of the bTB area in Michigan is privately owned  which ha0% of theAn additional novel tool that could aid eradication of bTB in Michigan is an oral vaccine against bTB for deer. Interest in using a vaccine for bTB in deer is increasing , 63, 86.M. bovis results in the presence of specific peptides in the blood which can be detected with common laboratory analyses , with public servants from natural resource and agricultural agencies struggling to regain healthy wildlife and livestock populations for them. It seems that through efforts to achieve healthy deer densities in Michigan following the appearance of bTB, public resentment has actually grown , 62. AgeGoing forward, agencies need to (1) establish long-term, mutually agreed upon objectives, (2) develop well-defined strategies that align with those objectives, and (3) develop and implement practices to evaluate the efficacy of those strategies . All optIf the goal is still to eradicate bTB across Michigan as stated by the Governor in 1998, then the potential exists to make great strides. Actions should include but are not limited to: significantly reducing deer densities with focus on those in the vicinity of cattle operations, eliminating baiting and supplemental feeding, segregating wildlife and cattle/cattle resources, using habitat management to change the spatial distribution of deer, and deploying a vaccine for deer.If the goal is only to eliminate bTB in cattle, the strategy is relatively straightforward especially if all transmission is occurring only between deer and cattle . With caThe ongoing situation with bTB in Michigan has been a persistent and expensive management challenge for livestock producers and state and federal agencies for more than a quarter of a century. As biologists and public servants, we may feel ethically committed to ridding the landscape of this disease that impacts the wildlife resource and a primary agricultural industry. But unless the societal and related political support for this exists, perhaps we need to either stand down or double down. The situation in Michigan is a multi-faceted issue with several imposing barriers, ecologically and socially, that are impeding the possibility for progress toward eradicating the disease. The first and foremost challenge is inadequate public concern over the health of the deer population and cattle herd and subsequent lack of political support and action. This challenge obstructs many crucial steps in wildlife management toward eradication, including the banning of baiting and feeding, reducing host populations, and understanding and accepting the severity of the bTB situation across the landscape.If there was increased public concern about the occurrence of bTB in wildlife, livestock, and humans there would likely be compounded support and participation in actively pursuing eradication. As demonstrated during the era of market hunting, even before the advent of modern hunting tools and technologies , Americans demonstrated our ability to severely reduce, and in some cases, decimate deer populations when motivated. Conversely and more recently, due to changes in motivators, we have demonstrated our ability to develop large numbers and concentrations of white-tailed deer. Now we must refocus on maintaining populations of fewer but healthy deer in concert with the limitations of local agricultural goals and available natural vegetation types that can provide deer habitat. In 1949, Aldo Leopold wrote, “A thing is right when it tends to maintain the integrity, stability, and beauty of the biotic community, it is wrong when it tends otherwise” . NaturalThe toolbox contains much of what is needed to combat bTB in Michigan; including increased hunting license allocations, increased availability of disease permits, financial cost-share programs to increase biosecurity on farms, feeding and baiting bans, the use of educational stakeholder meetings, new novel tools to facilitate diagnosis and surveillance, and even a vaccine for deer or evaluating the use habitat manipulations to redistribute deer. None of these tools will be effective alone, they must be applied aggressively and in unison to complement each other. Progress has been made in understanding and managing livestock-wildlife interactions and the transmission of bTB in the Michigan landscape and recent decisions and new strategies have great potential.KV, ML, and HC contributed equally in the development of the idea, collection of the data, and preparation of the manuscript. KV fleshed out the original outline. ML drafted the manuscript and continually incorporated and massaged his, KV and HC's thoughts. All authors continually reviewed and edited the manuscript, producing the submitted draft.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. The handling editor declared a past collaboration with one of the authors HC.


Abnormal heart morphogenesis can result in congenital heart defects (CHDs) or inherited cardiomyopathies. Inappropriate gene expression , 2, exprWhile much is known about the clinical sequelae of CHDs, in many cases, the underlying molecular etiology remains undefined. For example, visceral heterotaxy results from the loss of left–right patterning during early embryogenesis, when the cell and molecular signaling cascades, which normally regulate sidedness pattern formation, are well-established. However, the spectrum of cardiac defects in many heterotaxy models and within patients with heterotaxy is more severe than what would be anticipated from a simple breakdown of sidedness patterning. The molecular basis for this is not understood. Similarly, the anatomical and clinical sequelae resulting from anomalies in ventricular septation and papillary muscle morphogenesis are well characterized. Moreover, multiple genes have been identified, which when dysregulated impact the development of these structures. How dysregulated gene expression mechanistically gives rise to these morphogenic defects is at best poorly understood. A similar case can be made for events that regulate maturation of the ventricular wall. Left ventricular noncompaction (LVNC) is recognized as a distinct form of cardiomyopathy, which results from a morphogenic defect. However, the molecular processes that underlie this defect are not well understood; understanding the underlying molecular mechanisms which give rise to LVNC is critical to effect improvements in diagnosis and care .Pediatric Cardiology. The 5th Riley Heart Center Symposium was held in Indianapolis, Indiana, on November 20, 2017.To promote interactions between clinical and basic scientists working on CHDs, the Riley Heart Center at Riley Hospital for Children, Indiana University School of Medicine, has organized a series of symposia focusing on various aspects of cardiac development. Previous symposia were entitled “Growth and Morphogenesis of the Ventricular Wall” (2008), “Transcriptional Unification of Heart Morphogenesis” (2009), “Cardiomyocyte Injury and Protection” (2010), and “Development of the Cardiac Conduction System and Arrhythmias” (2011). The proceedings of these symposia were published in special issues of Pediatric Cardiology. Several articles reviewing the topics discussed at the 5th Riley Heart Center Symposium (2017), entitled “Development and Repair of the Ventricle Wall,” are published in the prior and this issue of The symposium faculty included 14 leading clinical and basic scientists from the United States, Germany, and The Netherlands. Sessions at the symposium focused on (1) the genetic regulation of cardiac development, (2) the role of cell polarity in ventricular wall morphogenesis, (3) the cell and molecular basis for arrhythmic cardiomyopathies, and (4) cell cycle-based interventions to promote myocardial regeneration. The articles provide a state of the art review of basic and clinical studies focused on the regulation and evaluation of ventricular wall growth in experimental animals and in man. It is hoped that these proceedings, as well as those from future Riley Heart Center Symposia, will foster collaborative projects between clinical and basic researchers who are dedicated to improving the treatment, and ultimately preventing the onset, of heart failure in the young.


Wearable and portable digital devices can support self-monitoring for patients with chronic medical conditions, individuals seeking to reduce stress, and people seeking to modify health-related behaviors such as substance use or overeating. The resulting data may be used directly by a consumer, or shared with a clinician for treatment, a caregiver for assistance, or a health coach for support. The data can also be used by researchers to develop and evaluate just-in-time interventions that leverage mobile technology to help individuals manage their symptoms and behavior in real time and as needed. Such wearable systems have huge potential for promoting delivery of anywhere-anytime health care, improving public health, and enhancing the quality of life for many people. The Center for Technology and Behavioral Health at Dartmouth College, a P30 “Center of Excellence” supported by the National Institute on Drug Abuse at the National Institutes of Health, conducted a workshop in February 2017 on innovations in emerging technology, user-centered design, and data analytics for behavioral health, with presentations by a diverse range of experts in the field. The workshop focused on wearable and mobile technologies being used in clinical and research contexts, with an emphasis on applications in mental health, addiction, and health behavior change. In this paper, we summarize the workshop panels on mobile sensing, user experience design, statistics and machine learning, and privacy and security, and conclude with suggested research directions for this important and emerging field of applying digital approaches to behavioral health. Workshop insights yielded four key directions for future research: (1) a need for behavioral health researchers to work iteratively with experts in emerging technology and data analytics, (2) a need for research into optimal user-interface design for behavioral health technologies, (3) a need for privacy-oriented design from the beginning of a novel technology, and (4) the need to develop new analytical methods that can scale to thousands of individuals and billions of data points. Digital technologies offer unprecedented opportunities to better understand and enhance behavioral health—individuals’ cognitive, emotional, and behavioral well-being. Behavioral health includes areas of substance use and mental health, and also embraces a broader spectrum of behavior  which may impact individuals’ quality of life and health outcomes. Given the widespread access to technology worldwide, health monitoring and behavior change tools delivered on mobile platforms enable widespread reach and scalability of evidence-based interventions.The rapidly evolving interdisciplinary field of behavioral health is making increased use of emerging technologies, novel methodologies, and data analytics in the development of effective and personalized digital therapeutic interventions. These technologies include mobile and wearable devices, and enable the delivery of personalized, “in the moment” interventions to empower patients and improve health. Novel sensing technologies allow for real-time measurement of a range of physiological, behavioral, and social activities and can help inform optimal timing of delivery of mobile interventions. Social media can be harnessed for rich data mining to develop a deeper understanding of both individual and population-level trends in health behavior and can serve as novel platforms for the delivery of behavior-change interventions. Increasingly sophisticated data analytics can be used to gain insights from mobile, sensor, and social data about individual and population health via advanced statistical methods, including machine learning and predictive modeling. Collectively, these digital technologies enable an entirely new offering of tools for collecting rich data about individuals’ behavior, health, and environment, provide personalized interventions and resources based on individuals’ needs and preferences, and enable dynamic statistical models and computational methods to predict and characterize individuals’ changing needs and health trajectories over time.The Center for Technology and Behavioral Health  is an interdisciplinary research center at Dartmouth College focused on the use of scientific methods to inform the optimal development, systematic evaluation, and sustainable implementation of a wide array of digital therapeutic tools for behavioral health  . In FebrDavid Kotz (Computer Science) observed that trends in health care information technology are leading to increased interest in monitoring of patients outside the clinical setting, through wearable and location-based, at-home technologies. He provided his own working definition of “mobile health”, or mHealth, as “the use of mobile computing and communications technology in the delivery of health care or collection of health information,” giving examples ranging from clinical to home use of mobile devices, to personal wellness apps, to opportunities for mHealth in the developing world.Ryan Halter (Engineering) described four projects underway at Dartmouth, beginning with Amulet [Kofi Odame (Engineering) spoke about his work in ultra-low-power analog electronics, for example, in measuring wheezing, coughing, and related sounds from a wearable microphone. In a new project, Auracle [Bill Kelley  spoke about his use of smartphone sensing for a months-long study of student dysphoria, depression, and mental health in free-living conditions. They found strong correlations between the data from passive smartphone sensing with self-reported  [Three other speakers described specific opportunities for mobile sensing in behavioral health. h Amulet ,3, a col Auracle , Halter,nt; EMA)  responsent; EMA) .All the speakers expressed great optimism for the future of wearable and mobile sensing technology, bringing new insights into behavioral health and new opportunities for effective interventions, while noting significant research challenges ahead.Sarah Lord (Psychiatry and Pediatrics) raised three key questions for panelists: (1) What are the best practices guiding UI/UX for digital approaches to behavioral health? (2) What are the common challenges to effective UI/UX and effective solutions to overcome those challenges? (3) How can we foster a common language among interdisciplinary teams to facilitate a successful UI/UX process for digital therapeutics for behavioral health?The ease of use and aesthetic qualities of innovations, such as digital therapeutic interventions, are critical to successful dissemination and implementation of such innovations ,8. PreseCraig Ganoe (Data Science) provided a brief history of the field of human-computer interfaces and UI/UX, from early engineering emphasis on system performance to current iterative participatory design and development approaches. Ganoe highlighted consideration of the task-artifact cycle [ct cycle , emphasiLorie Loeb (Computer Science) noted that effective UI/UX promotes motivation through appeal to both emotional and intellectual aspects of individuals and presented case examples to demonstrate effective UI/UX of digital approaches for behavior change. In one case, college students worked iteratively with researchers to design and develop a simple, colorful, engaging kiosk to elicit stress assessment by college students. A 2-week pilot of the kiosk in a high traffic area of the college library yielded over 8000 responses, and positive feedback by students . In another case, Loeb used animation (of polar bears struggling with climate change) and data visualization (of dormitory energy-use data) and found increased energy conservation among college students [students .Xing-Dong Yang (Computer Science) highlighted cutting-edge basic research focused on interaction techniques with wearable devices. Yang demonstrated an early prototype of a smartwatch face that orbits on the wristband, allowing for ready access to the watch features at any time with minimal intrusion [ntrusion . Yang emJames O’Malley (Data Science) noted that just a few decades ago there was a sentiment among academic statisticians that “the best statisticians do not work with data,” a reflection of the focus on independent theoretical and methodological work in promotion criteria for tenure-line university-based statisticians and biostatisticians. The computing evolution has led to a reversal of priorities, with data extraction, manipulation, analysis, and presentation all deemed highly important.Informatics and data analytics play an increasingly important role in understanding behavior, designing behavioral interventions, and interpreting data from behavior-related sensors. Emily Scherer, a biostatistician, described how the already-broad skillset of a biostatistician has changed due to a need to use or develop more complex analytic approaches and data gathering or acquiring techniques  than those used in traditional randomized clinical trials and other common statistical domains or problems. For example, EMA data is an increasingly useful form of intensive longitudinal data [Three panelists spoke about the role of mobile phone and other emerging technologies in their behavioral-health research. nal data . Althougnal data .Saeed Hassanpour (Data Science) and Benjamin Crosier (Data Science) presented research characterized by large, complex, and unbalanced data sets. Hassanpour, an expert in natural-language processing, uses novel algorithms for reducing text and imaging data to forms that Crosier, an expert in quantitative social psychology, can use. They use Instagram location and network data to assess the impact of social media on a patient’s behavioral risk. They also use deep learning and convolutional neural networks to identify recurring patterns in data and classify observations or participants into groups and use other machine-learning methods to develop prediction rules often without using fully-specified statistical models.All three—Scherer, Hassanpour, and Crosier—benefit from “Big Data” generated from enhanced monitoring capabilities, electronic medical records, high-throughput technologies, and networked research resources.David Kotz (Computer Science) observed, several trends in information technology development make privacy and security concerns in health care especially acute. These trends include the need for accountable care and patient engagement, and continuous patient monitoring outside the clinical setting. Emerging threats and a changing regulatory environment further emphasize the importance of security and privacy in all digital technologies in health care settings.Privacy and security are central problems for many digital apps, and as mHealth technologies, enabled by the advent of mobile devices and cloud services for health-related apps, present an additional set of challenges. Given the immediate, personal impact of these devices, security and privacy concerns are even more acute. mHealth devices directly affect users’ health or health decisions, and mHealth data are inherently personal and thus highly sensitive. In addition, mHealth apps collect longitudinal data, including behavioral information, from a broad range of lifestyle activities—data which have the potential to be analyzed to produce insights about mood and personality. Perhaps most concerning, the mHealth sector encompasses a broad range of apps unbound by specific regulations protecting health data privacy. As witnessed by the recent controversy over Cambridge Analytica’s psychographic analysis of illicitly-obtained Facebook user data, these matters are increasingly matters of extreme societal concern.Denise Anthony (Sociology) and Luke Stark (Sociology) discussed some of the central questions around privacy, security, and the broader social use of mHealth technologies, including the growing field of applications focusing on substance use and mental health. Key questions highlighted for future exploration included identifying what laws, policies, regulations and guidelines are currently in place to shape the technical developments around privacy and security in mobile health, and whether they were adequate for technical developments in the field; and what determining what kind of research was being conducted on the empirical impact of mobile health devices, particularly as related to their privacy affordances and security vulnerabilities. The three also discussed how human factors in UI/UX design, especially work on privacy-preserving or enhancing technologies and the broader tenets of privacy by design, could be part of the solution to the privacy and security concerns with mobile devices, and which laws and regulations might need modification to align with the privacy and security affordances of mobile-health technologies.Kotz, joined by The day-long multidisciplinary workshop left attendees feeling energized and excited about the potential for emerging technologies and data analytics to bring new insights to behavioral health, and new opportunities for innovative interventions. A few of the insights and recommendations from the presentations and conversation at the workshop are listed below.Wearable devices bring new opportunities for sensing, computation, and interaction, with potential far beyond the capabilities of today’s fitness trackers and smartwatches. Sensor-design engineers should work closely with behavioral health scientists to understand what information would be most insightful, and seek innovative, unobtrusive mechanisms to collect that information.Many behavioral-health studies (or interventions) use wearables, smartphones, and Web portals to interact with participants (or patients)—and yet, it remains a challenge to design interfaces that are efficient, effective, acceptable, and usable by target populations. Indeed, without careful thought to the user experience, including physical design of wearable devices and the user’s interaction with physical or digital interfaces, otherwise-innovative technologies may not be effective, or even adopted. Behavioral-health scientists and UI/UX designers should work collaboratively when developing technology-based interventions, and ideally with iterative input from representatives of the intended target end-users of the intervention.New technologies can produce enormous amounts of data, rich with potential for insights into human behavior but require new approaches to analysis. Studies may involve hundreds, thousands, or even tens of thousands of participants—and billions of data points—requiring the application of innovative approaches in statistical methods, machine learning, and data analytics. Health researchers and data scientists should collaborate to bring new approaches to these rich new data sources.Privacy should be a key factor in the design of all behavioral-health technologies, from conceptualization through prototyping and potential commercialization. Numerous design principles and heuristics, most notably those of privacy by design, are available as resources in these endeavors. Consistent with these design principles, designers and researchers should seek effective means to communicate to the end-user about what data is being collected, how it will be used, who will have access, and how it can be disposed. Poor attention to privacy may impede adoption, especially in a global regulatory context, now including the European Union’s General Data Protection Regulation, whereas strong privacy protections can encourage adoption among sensitive populations.Mobile technologies can collect a wide range of data about individuals, including types of data not traditionally considered to be protected health information or personally identifiable information, but which  can extract insights about sensitive behaviors and even reidentify anonymous individuals. Technology developers should limit data collection to only that which is needed, avoid transmitting and storing raw sensor data, and put strong technical and administrative controls on secondary use of data.The Center for Technology and Behavioral Health at Dartmouth, as a community of researchers from sensor engineering, computer science, data analytics, psychiatry, and behavioral health, is poised to pursue these opportunities, and encourages researchers everywhere to engage with these exciting challenges.


Patient safety is challenging for health systems around the world, particularly in low-and middleincome countries such as Guatemala. The goal of this report is to summarize a strategic planning process for a national patient safety plan in Guatemala.This strategic planning process involved multiple stakeholders, including representatives of the Guatemala Ministry of Health and Social Assistance, medical leadership from across the public health system, and academic experts from Guatemala and the United States of America. We used mixed methods  and a nominal group technique at a national symposium to prioritize patient safety challenges across Guatemala, and subsequent meetings to develop a national patient safety plan.This national patient safety plan outlines four domains to advance patient safety across the public hospital system over a five-year period in Guatemala: leadership and governance, training and awareness, safety culture, and outcome metrics. For each domain, we developed a set of goals, activities, outputs, and benchmarks to be overseen by the Ministry of Health.With this national patient safety plan, Guatemala has made a long-term commitment to improving patient safety across the public hospital system of Guatemala. Future efforts will require its extension to all levels of the Guatemalan health system. Patient safety is increasingly recognized in the global health agenda as a central component of a high-quality health system , 2. The Medical errors are particularly hazardous in low- and middle-income countries (LMICs) such as Guatemala, where the risks of health care–related complications far exceed those in high-income countries , 5. SpecHealth systems around the world have adopted common strategies to promote patient safety, including enhanced systems to measure medical errors, use of performance indicators, and implementation of evidence-based clinical guidelines . SeveralGuatemala’s health system faces many internal and external challenges , 13. SimDespite several programs to improve health outreach in the public health system, particularly in rural areas and in primary care, wide disparities in health care and outcomes remain across Guatemala. For example, the North and Northwest regions have the country’s highest maternal mortality ratio (MMR), which is a common metric of health care quality, as well as the highest prevalence of stunting . Most ofWithin this context, a working group composed of MSPAS representatives, medical and hospital leaders, academic experts from the University of San Carlos of Guatemala (USAC) and Duke University , and local nongovernmental organization personnel initiated a strategic planning process to improve patient safety. Following a kickoff symposium in October 2018, this interdisciplinary group of stakeholders developed a national patient safety plan, which was endorsed by the Ministry of Health in April 2019.The goals of this commentary are to summarize this strategic planning process, identify priorities for patient safety, and develop a framework to improve patient safety across the public health system in Guatemala.To initiate this strategic planning process, we first performed a stakeholder analysis at a symposium held in Guatemala City in October 2018. Invitees included hospital directors from all 38 public hospitals across the country, representatives from the MSPAS and from private hospitals, and academic leaders from Duke University and USAC. The final slate of attendees included 36 public hospital directors representing all 22 departments of Guatemala; 13 representatives from the MSPAS, including the vice minister of hospitals; 1 private hospital director; and 10 academic leaders from Duke University and USAC. The goals of this symposium were to: 1) identify challenges to patient safety within the Guatemalan public health system and 2) prioritize strategies to improve patient safety.We collected data from public hospital directors  using several methods. To identify challenges to patient safety, we used quantitative surveys and guided group discussions. Participants were first asked to identify, discuss, and rank problems in patient safety at their home institution using a written survey. To prioritize interventions, we led focus group discussions using a nominal group technique to prioritize health care safety concerns . ThroughAlmost all (98%) of the symposium participants consider the Guatemala health system to have significant problems in patient safety and health care quality. There was wide variation among hospital leadership in regard to awareness and use of patient safety policies, although most directors cited a need to expand local patient safety systems. Most participants cited a lack of awareness of patient safety among health care staff, with only 27% of directors thinking that their staff had adequate knowledge about patient safety. Critical barriers included a lack of national health policy on patient safety, insufficient training in patient safety for health care personnel, and lack of staff awareness of the importance of patient safety. We triangulated data from focus group discussions and written surveys to develop a final ranking of national patient safety priorities .Following data analysis, the working group collaborated over the next three months in developing short-term and longterm strategies to improve patient safety and health care quality as well as providing a framework for a national patient safety plan. This strategic planning process involved triangulation of quantitative survey data, evaluation of discussions from the symposium, and a series of meetings to drive consensus to prioritize interventions and strategies.There were four key high-ranking short-term interventions (< 12 months) to improve patient safety. The first concerned leadership and organization. A national Patient Safety Leadership Committee composed of multiple stakeholders should be developed to establish priorities for patient safety efforts across the public health system. Stakeholders should include public and private medical sector leaders, government officials, patients, and national and international experts in patient safety. The second intervention dealt with training, with training core staff across the public health system at the local level to lead interdisciplinary patient safety teams. The third short-term invention focused on safety culture and awareness, with the use of data-driven tools to promote safety culture and awareness among health care staff and the general population. The fourth concerned research, with the expansion of research capacity to assess patient safety, evaluation of the economic impact of patient safety, and tackling of implementation challengesThe proposed intervention strategies for the medium to long term (one to five years) covered four areas. The first was national policy development, including developing a national policy on patient safety and health care quality, as well as defining standards, priorities, and framework for patient safety. The second area was informatics, in terms of developing and supporting infrastructure for adverse event reporting. The third was training, with the expansion of patient safety education programs for health care staff, and the integration of patient safety and leadership content into medical education. The fourth area was harmonization, through the unification of regional and national quality improvement and patient safety initiatives.The strategic working group used this information to develop a national patient safety plan. We first developed a framework to support patient safety across the public hospital system based on principles of several international patient safety organizations and of the World Health Organization (WHO) , 20. UseThe national patient safety plan outlines four domains to guide patient safety initiatives: leadership and governance, training and awareness, safety culture, and outcome metrics . For eacWe recognize several limitations to this national patient safety plan. First, as this program is focused towards patient safety in public hospitals, not all stakeholders in the Guatemalan health system were included in the planning process, particularly from primary care and rural settings. To equitably support patient safety across the Guatemalan health system, other groups should be included as this program is further developed, including with representation from the IGSS, the Health Care Unit of Indigenous Peoples and Interculturality (UASPII), National Reproductive Health Program (PNSR), General Directorate of the Comprehensive Health Care System (DGSIAS), Health Areas Directorates (DAS), Ombudsman’s Office for Indigenous Women (DEMI), and the Presidential Secretariat for Women (SEPREM). Second, we recognize that Guatemala has some of the lowest levels of public health investment in Latin America, suggesting that increased government investment may be required to implement this patient safety agenda , 22. ThiThis national safety plan represents Guatemala’s long-term commitment to improving health care quality and patient safety, and will be a core element of the MSPAS’s operations. This national patient safety plan is a necessary key—but only first—step towards driving improvements in patient safety. Although the national patient safety plan is one indicator that the building blocks are in place to provide high-quality care, a national strategy alone has limited capacity to promote action. To augment these policy efforts, we advocate efforts to promote a “just culture,” or support a safety culture that values transparency, communication, and investment in trained personnel and systems to promote continuous quality improvement .Standardized, locally applicable quality indicators are required to monitor progress in health care quality . QualityOur experience may be helpful for other countries that are developing national safety plans, as all countries face complex challenges in patient safety. A national patient safety plan should be contextualized to a country’s resources and health delivery challenges. These kinds of plans provide a framework to define the role of government and other stakeholders in assuring patient safety across the health system; clarify responsibilities and relationships; and identify incentives to support optimal performance in the provision of high-quality care. We encourage an implementation framework to embed patient safety programs in existing health delivery systems. Finally, we emphasize the need for education of health care providers in quality improvement and patient safety, as well as support for formal training of local experts to lead patient safety efforts.Randall Lou-Meda: study design and manuscript preparation; Sindy Méndez: data collection; Erwin Calgua: study design; Mónica Orozco: data analysis; Bria J. Hall: study design, data collection, and manuscript preparation; Natalie Fahsen: data collection; Brad M. Taicher: study design; Joseph P. Doty: study design; Julio García Colindres: study design; Carlos Soto Menegazzo: study design; and Henry E. Rice: study design, data collection, and manuscript preparation. All the authors reviewed and approved the final version.We thank the FUNDEGUA foundation, Fundanier foundation, University of San Carlos of Guatemala, Duke Global Health Institute, and Guatemala Ministry of Public Health and Social Assistance  for their support. No funding agency influenced, in any way, the design, data collection, analysis, writing, or decision to publish these results.RPSP/PAJPH and/or PAHO.The authors hold sole responsibility for the views expressed in the manuscript, which may not necessarily reflect the opinion or policy of the


People living with HIV are increasingly burdened by noncommunicable diseases (NCDs) as a result of the NCD susceptibility that accompanies increased life expectancy and the rising global prevalence of NCDs. Health systems are being strengthened and programs are being developed to address this burden, often building on HIV care strategies and infrastructure or through integrated care models. HIV remains a stigmatized condition and the role of HIV stigma in the provision of NCD care is not well understood.We conducted a scoping literature review of both peer reviewed and grey literature to identify evidence of the role of HIV stigma in the NCD-care continuum . We searched PsychInfo and Pubmed and conducted additional searches of programmatic reports and conference abstracts. Included studies were published in English within the past decade and examined HIV-related stigma as it relates to NCD-care or to integrated NCD-and HIV-care programs.Sixteen articles met the inclusion criteria. Findings suggest: fear of disclosure, internalized shame and embarrassment, and negative past experiences with or negative perceptions of health care providers negatively influence engagement with NCD care; HIV stigma can adversely affect not only people living with HIV in need of NCD care, but all NCD patients; some NCDs are stigmatized in their own right or because of their association with HIV; integrating NCD and HIV care can both reduce stigma for people living with HIV and a present a barrier to access for NCD care.Due to the dearth of available research and the variability in initial findings, further research on the role of HIV stigma in the NCD-care continuum for people living with HIV is necessary. Lessons from the field of HIV-stigma research can serve as a guide for these efforts. People living with human immunodeficiency virus (PLHIV) across the globe now live longer due to the improvements in and expanded access to antiretroviral therapy (ART) –4. AlongGiven the growing burden of NCDs in both the general population and among PLHIV, health care systems must be strengthened to provide needed NCD services. To meet this need, policy makers are beginning to draw from the extensive investment in strategies and systems that support lifelong HIV care and the lessons learned from HIV treatment scale-up –18. ProgOne key factor that negatively impacts care is HIV-related stigma and discrimination. Stigma and discrimination persist in health care delivery systems across the globe, violate human rights and hinder access and engagement in the HIV-care continuum –29. PLHIConsequently, the growing number of people in need of NCD care, the increased susceptibility of PLHIV to NCDs, and the persistence of HIV stigma as barriers to care, all point to the potential for HIV stigma to undermine the NCD-care continuum. In order to strengthen efforts to reduce NCD risk and improve NCD care in general and for PLHIV in particular, an improved understanding about whether and how HIV stigma impact NCD diagnosis and care is needed . Thus, tWe conducted a scoping literature review to identify existing evidence of the role of HIV stigma on the NCD-care continuum. Our objectives were to document the available evidence describing the role of HIV-related stigma on any aspect of the continuum of care for NCDs and identify the emerging themes related to HIV-stigma and either NCD care or the integration of NCD and HIV care. The “continuum of care” was defined as prevention, diagnosis, care seeking, retention in care, and adherence to treatment. NCDs were limited to the priority NCDs under the Sustainable Development Goal 3: cancer, cardiovascular disease, chronic pulmonary disease, diabetes, anxiety, and depression  We presest International AIDS Conference (AIDS 2016) and the 9th International AIDS Society (IAS) Conference on HIV Science (IAS 2017). We used the following search terms were used to identify relevant literature: “HIV” paired with either “stigma,” “discrimination,” or “attitudes” in addition to “hypertension,” “cardiovascular disease,” “diabetes,” “chronic respiratory,” “chronic pulmonary disease,” “cancer,” “depression,” “anxiety,” or “mental health.” See the supplementary materials for an example of the full search strategy.We conducted a broad search of peer-reviewed, grey (programmatic) literature and conference abstracts. We searched PsychInfo and Pubmed to identify peer-reviewed literature. Additionally, we conducted targeted searches of grey literature databases such as the US Centers for Disease Control and Prevention Stacks, US Agency for International Development’s Development Experience Clearinghouse, and conference abstracts from the 21From the search, the identified peer-reviewed citations and abstracts were uploaded, organized and reviewed using Covidence (a systematic review software) from their respective databases Two reviewers (MAS and KG) independently screened titles and abstracts for eligibility. These same two reviewers screened grey literature within their respective databases. The senior author (LN) discussed any discrepant assessments and resolved any outstanding disputes.We included articles describing: (1) research measuring HIV-related stigma and its association with or effect on the continuum of care for NCDs; (2) research exploring HIV-related stigma as it relates to the continuum of care for NCDs; (3) programs or interventions addressing HIV stigma towards PLHIV seeking care for NCDs; (4) integrated NCD- and HIV- care programs that examine HIV stigma; or (5) reviews that provide insight on the aforementioned topics. In an effort to capture all available evidence, we did not restrict the study geography or methodology. Additionally, we only included articles published in the last 10 years prior to May 30, 2017 and written in English. However, we excluded studies if they examined the association between HIV stigma and risk factors for NCDs  or exclusively examined stigma related to NCDs .We exported the title, author, journal and year of publication for studies that met the inclusion criteria into an excel spreadsheet for data abstraction and charting. The same two authors independently abstracted data on the following topics from each included article: country, NCD examined, study type and design, population, NCD outcomes examined, type of stigma(s) measured or examined, and key findings. We then organized key findings into the following categories: the role of HIV stigma in NCD care; the role of stigma related to NCDs and other factors in NCD care; inter-related stigmas; and stigma as it relates to integration of NCD and HIV care. Abstracted data were reviewed for consistency, and the senior author (LN) discussed any discrepancies and settled any disputes.Additionally, the two reviewers appraised all included articles using the Joanna Briggs Institute tools recommended for mixed method reviews synthesizing at least two types of data –39. The We identified 663 peer-reviewed abstracts and 40 were advanced to a full-text review. Of the 40 articles that underwent full-text review, 16 met the inclusion criteria.  None of The review yielded 16 articles and 15 distinct studies . Of noteNone of the included articles were excluded following appraisal with the quality assessment tools. The qualitative studies’ scores ranged between 6 and 8 out of 10, the randomized control trial scored 9 out of 12, and the cross-sectional and longitudinal studies’ scores ranged between 4 and 8 out of 8.  Due to tFour studies used or adapted established stigma measures –42, 44. The review revealed several studies (n = 15) that examined the role of HIV stigma along the NCD-care continuum; six studies examined prevention; three studies examined diagnosis and treatment; two studies examined general care seeking and two studies examined the provision of care. No studies examined the role of HIV stigma as part of treatment adherence or retention in NCD care. Of the included studies, we identified only one intervention that included specific stigma-reduction efforts  as part All of the studies (n = 6) that examined HIV stigma and NCD prevention examined cervical cancer screening , 46–48. Three studies examined the role of HIV-stigma in NCD diagnosis and treatment, and all focused on identifying and managing depression , 49, 50.Two studies examined HIV stigma and general care seeking for NCDs , 51. A sOnly two studies examined HIV-stigma reduction as part of the provision of NCD care to PLHIV , 51. TheNCDs may carry their own stigma. Seven articles discussed stigma related to cervical cancer , 48, 52,Individuals may also face discrimination that influences their health for reasons unrelated to their health status and belonging to multiple stigmatized groups has been shown to compound the negative effects of stigma, though the mechanisms and degree to which this occurs is not well understood . While nOnly one study discussed stigma or discrimination not specifically related to a health condition. This study on cervical cancer screening among African Americans living with HIV recognized the potential role of racial discrimination. This study found that, in addition to the detrimental effects of the perception that medical providers hold negatives attitudes towards PLHIV, believing providers hold negative attitudes towards racial and ethnic minority groups also hindered access to cervical cancer screening .As NCD- and HIV-care programs are increasingly being integrated into one another or into the primary health care system, this review included selection criteria to identify integrated programs that recognized the role of HIV stigma in seeking and delivering NCD care. Five such articles on integrated NCD- and HIV-care programs were identified. Of these articles, three evaluate existing integrated chronic disease programs that provide care to both PLHIV and NCD patients , 53, 55;Four studies found that HIV stigma would hinder access to care for HIV-negative NCD patients, as they may be reluctant to access care from programs that are integrated with HIV care , 55, 56.Four studies examined the potential effects of various integrated models of care on HIV stigma, and all four concluded some level of integration could potentially result in HIV-stigma reduction for PLHIV , 53, 55.The studies identified in this literature review, while few in number, provide some useful insights. In particular, findings suggest that fear of disclosure, internalized shame and embarrassment, and negative past experiences with or perceptions of health care providers as stigmatizing all negatively influence engagement with NCD care for PLHIV , 53, 56.Previous research efforts compliment many of our findings. Other studies have shown that PLHIV may be more likely to either fear or actually encounter both inadvertent or intentional discrimination when accessing care in settings where providers are less familiar with HIV , 58. ResHIV infrastructure and care strategies are being utilized to meet NCD needs, particularly in low-resource settings. After decades of investment in stopping the HIV epidemic, many systems have been established that can support lifelong chronic care and have been adapted to a variety of settings , 18. As Findings from this literature point to a need to further understand how HIV stigma may affect NCD care for both PLHIV and non-PLHIV and to expand investment in HIV-stigma reduction. Many of the included articles concluded by recommending such further research and investment –51, 56. The authors wish to acknowledge several limitations of this scoping review. The abstract screening, full text review, and data charting processes in scoping reviews are inherently subjective. However, efforts to limit subjectivity were made, and each step in the review process was conducted by two researchers with supervisory input from the senior researcher. In addition, this topic has received severely limited attention in the literature. While careful attention was given to assessing the methodological quality of included studies, the researchers aimed to identify any evidence that would provide insight into HIV stigma and NCD care. The results of quality appraisal demonstrated that the quality of included studies varied , which mThe global burden of NCDs is on the rise, particularly among PLHIV as a result of the nature of HIV and side of effects of its treatment. As health care systems are adapting to meet this epidemiological shift, HIV infrastructure, care strategies, and resources are being leveraged to provide NCD care to both PLHIV and HIV-negative patients. While the detrimental role HIV stigma plays in the HIV-care continuum is well recognized, its potential to deter or disrupt NCD care is not well understood. This literature review suggests that fear of disclosure, internalized shame and embarrassment, and negative past experiences with or perceptions of health care providers negatively influence engagement with NCD care. Furthermore, findings highlight some of the ways HIV stigma can adversely affect not only PHLIV in need of NCD care, but all NCD patients. Some NCDs were shown to be stigmatized in their own right as well because of their association with HIV. Studies included in this review found that integrating NCD and HIV care can both reduce stigma for PLHIV and a present a barrier to access for NCD care. Due to the dearth of available research and the variability in initial findings, further research to explore the role of HIV stigma in the NCD-care continuum for PLHIV is necessary. Lessons from the field of HIV-stigma research can serve as a guide for these efforts.S1 File(DOC)Click here for additional data file.S2 File(DOCX)Click here for additional data file.


The health impacts of community design have been studied extensively over the past two decades. In particular, public transportation use is associated with more walking between transit stops and shops, work, home and other destinations. Change in transit access has been linked with physical activity and obesity but seldom to health outcomes and associated costs, especially within a causal framework. Health related fiscal impacts of transit investment should be a key consideration in major transit investment decisions.The Rails & Health study is a natural experiment evaluating changes in clinical measures, health care utilization and health care costs among Kaiser Permanente Northwest (KPNW) members following the opening of a new light rail transit (LRT) line in Portland, Oregon. The study is prospectively following 3036 adults exposed to the new LRT line and a similar cohort of 4386 adults who do not live close to the new line. Individual-level outcomes and covariates are extracted from the electronic medical record at KPNW, including member demographics and comorbidities, blood pressure, body mass index, lipids, glycosylated hemoglobin, and health care utilization and costs. In addition, participants are surveyed about additional demographics, travel patterns, physical activity (PA), and perceived neighborhood walkability. In a subsample of the study population, we are collecting direct measures of travel-related behavior—physical activity (accelerometry), global positioning system (GPS) tracking, and travel diaries—to document mechanisms responsible for observed changes in health outcomes and cost. Comprehensive measures of the built environment at baseline and after rail construction are also collected. Statistical analyses will (1) examine the effects of opening a new LRT line on chronic disease indicators, health care utilization, and health care costs and (2) evaluate the degree to which observed effects of the LRT line on health measures and costs are mediated by changes in total and transportation-associated PA.The results of the Rails & Health study will provide urban planners, transportation engineers, health practitioners, developers, and decision makers with critical information needed to document how transit investments impact population health and related costs. Rates of overweight and obesity have steadily risen in the last half-century and obesity is now one of the largest modifiable health risk factors for numerous common diseases, including diabetes, hypertension, cardiometabolic disorders, cancer, asthma, depression, and musculoskeletal disorders. –9 NearlyBecause these health problems are partially attributable to sedentary lifestyles, a promising area of research is now focusing on measuring the health impacts of the built and natural environment where people live and work. Researchers are investigating the population-level health impacts of changes in travel patterns resulting from transportation investments and land use patterns or local “walkability,” –21 and hGrowing evidence of the role of community design and the built environment in stimulating an active lifestyle has led to an increase in environmental interventions intended to promote PA.  However,The Rails & Health study is a longitudinal natural experiment that examines the impact of a major public transportation infrastructure improvement—the opening of a new light rail transit (LRT) line—on clinical health outcomes and health care utilization and costs. The study seeks to leverage unique and robust observational research data to advance our understanding of the multi-faceted impacts of large-scale transit investments on public health. This article describes in detail the Rails & Health study design, including participant recruitment, an extensive objectively-measured and self-reported health and environmental data acquisition effort, measurement methods, and statistical analyses. We also present strategies used to establish consistent, participant-specific neighborhood environmental measures related to community walkability, access to destinations and services, and social contexts.The primary aim of the Rails & Health Study is to examine the impact of opening a new LRT line on chronic disease indicators, health care utilization, and health care costs. The case-control design compares 3036 adults who live near the rail line to 4386 adults with similar demographic characteristics who live in similar areas away from the rail line Fig. . To addrThe second aim of the study is to evaluate the degree to which the observed impact of the LRT line on chronic disease indicators and health care utilization and costs are mediated by changes in total and transportation-associated PA Fig. . To addrThe study evaluates the impact of the Portland–Milwaukie Light Rail Project, also known as the Orange Line, which opened in September 2015. The Orange Line is a 7.3-mile, 10-station addition to the 53-mile, 87-station Metropolitan Area Express (MAX) light rail system of the Tri-County Metropolitan Transportation District of Oregon (TriMet). TriMet is the public agency that operates mass transit in the Portland, Oregon metropolitan area. The new line connects downtown Portland to the City of Milwaukie, directly to the south, and includes the first multi-modal, car-free river bridge in the U.S. and concurrent improvements to pedestrian infrastructure within LRT station areas.Study participants are members of Kaiser Permanente Northwest (KPNW), an integrated health care system that provides ambulatory and hospital care to more than 600,000 patient-members in northwest Oregon and southwest Washington. Critical to this study, KPNW uses a comprehensive EMR, member addresses are updated frequently, and historical addresses are maintained.Participants in the overall cohort are aged 18–74 years and have lived at their current address for at least three years prior to the LRT line opening in September 2015. From among the pool of eligible participants, cases were identified as participants who had residential addresses in census block groups within a 1.5-km road network buffer of one of the new LRT stations on the Orange Line , signed consent was waived for the behavioral cohort.All demographic and clinical covariate data, clinical outcome data, and health care utilization data were extracted directly from the KPNW EMR (an instance of Epic®). These measures were collected for the overall cohort for the three years before and after the LRT line opened.The clinical outcomes for the primary study aim obtained from EMR laboratory and encounter data are blood pressure, BMI, non-HDL cholesterol, and HgbA1c. Health care utilization is collected from EMR encounter data and includes average monthly outpatient visits, average monthly length of inpatient stays, and average total monthly medication utilization. Pharmacy dispensing data are also collected from the EMR since KPNW includes a closed pharmacy benefit. Health care costs are calculated using a Standardized Medical Care Costing Model developed at the Center for Health Research to account for all services, procedures, and products received by a member, as captured in the KPNW data systems.  DemograpThe transportation and neighborhood perceptions survey collected additional information about transportation use, perceived PA, and perceived neighborhood characteristics prior to and after the opening of the LRT line (survey available from the authors). These data will be used in descriptive analyses and as covariates in models that examine whether potential changes in clinical, utilization, and cost outcomes related to the LRT line are impacted by PA and transit use. The survey includes self-report measures of: (1) demographics, including income, education, race, ethnicity and social habits ; (2) physical functioning, or functional status, as measured through a validated 10-item short form recommended by the NIH Patient-reported outcomes system (PROMIS) , 46; (3)Physical activity was objectively measured with GT3X+ accelerometers . The GT3X+ is a triaxial monitor that detects acceleration in the vertical, anteroposterior, and mediolateral axes.  ParticipGeographic position and instantaneous movement speed provide contextual information about PA behaviors such as the location of an activity and the mode of transportation. These data were collected using the BT Q1000XT GPS Travel Recorder . Participants were asked to wear or carry the portable travel recorder for seven days, concurrent with accelerometer use and travel diary data collection. The device can be attached to the accelerometer belt or another belt and works up to twenty hours when set at 15-s epoch acquisition.Participants in the behavioral cohort also completed a written travel diary for each day of accelerometer and GPS wear. The travel diary is based on the 2009 National Highway Transportation Survey, with additional questions about recreational travel.  ParticipData from the GPS and accelerometer units were cleaned, processed, and merged using the All-in-one Spatial Activity Processor, an open source tool developed by researchers at Portland State University.  The toolOnce GPS and accelerometer data were merged, discrete trips were differentiated using methods that examine speed variations and time spent at specific destinations. Travel mode  was ascertained based on travel speed, route, and transportation network characteristics.  IndividuTravel diary information was entered into a database and algorithms were used to identify missing and possibly erroneous data prior to merging it with GPS and accelerometer data. Trip records were flagged for any of the following errors: trip ended before it started; trip departed before the preceding trip arrived; trip spanned more than 12 h. Research staff contacted participants as needed to fill in missing entries or to clarify erroneous entries.Merged accelerometer and GPS data were then joined to travel diary data by matching the arrival/departure times from the travel diary with the closest time stamp in the merged GPS and accelerometer data. Collectively, the data integration allows for validation of behaviors across data streams, provides additional information for data cleaning and imputation, and facilitates the derivation of summary PA metrics.We derived comprehensive measures of the built environment for each participant’s residence and workplace address at baseline. We will test how these measures—including neighborhood walkability; regional accessibility to destinations; seating, lighting, sidewalks, and other design features; and access to open space, moderate the effect of the LRT line opening on PA, clinical health measures, and costs.As a formative step in the creation of built environment measures, we assembled a comprehensive network that pedestrians can traverse, including roadways and non-motorized, multi-use pathways. This walkable network was used for three primary purposes: (1) defining the catchment area a participant can walk to within a given distance (street network buffer) from their home and their work, (2) determining the locations of intersections and cul-de-sacs, and (3) determining the network distance and walking travel times, from a participant’s home and work, to the nearest work and non-work destinations.We acquired a road centerline file and information describing pedestrian and cyclist non-motorized pathways from Metro, the metropolitan planning organization serving the Portland Region.  All roadRegional accessibility measures relative travel time and distance, by location and mode, to major, regionally-significant destinations. It is derived from regional travel demand models used to inform transportation investment decisions and is based on the trip distribution sub-model that predicts where people will go for given types of trips. It captures access to jobs, parks, shops, and other destinations within a given amount of time. The study used locations of regional significance defined by the Metro 2040 Growth Concept.  These lohttp://transitfeeds.com).The measures of regional accessibility included the network distance and estimated travel times (for both single occupancy vehicles and on transit) between all participant origin locations and regionally significant destinations, as well as an average measure of the network distance to these destinations. Auto travel time estimates were obtained from Metro using their modeled “centroid based” zone to zone travel times from the regional travel demand model. Zone to zone private vehicle travel times reflect actual or “congested” travel speeds for peak and off-peak periods. Transit travel time estimates for peak and off-peak  were calculated using General Transit Feed Specification transit schedule data , street connectivity or route directness, and retail floor area ratio or street setback, forming a composite measure of local accessibility. Walkability is a validated construct that captures variations in development patterns that are associated with behavior, including travel and PA. We focused on walkability variables that most influence choices about transportation mode . Spatial catchment areas, referred to here as buffers, originating at a participant’s home or work address, capture the area a participant can access on the road network for a given distance. State of the art “sausage” based network buffers see Fig.  were devThe Microscale Audit of Pedestrian Landscape (MAPS) tool is used to quantify microscale characteristics of street segments shown to have relevance for walking and other forms of PA.  Routes bPublic parks offer residents opportunities for physical activity among other health benefits. We counted the number of parks and calculated total park area intersecting and accessible within the 1-km sausage buffer around each participant’s residence and work location, as well as the distance from each residence and work location to the nearest park. We included only developed, public parks with regular municipal maintenance, excluding natural areas not meant for regular access by the public and private areas such as golf courses. We separated parks into three size categories: (1) small park, parklet, or pocket park (< 1 acre), (2) medium park (1–50 acres), and (3) large park or state park (> 50 acres).Crime is a significant factor impacting the perceived safety and comfort of walking in a neighborhood. Crime data were obtained from the uniform incident reporting system used by the Portland Bureau of Police tracking all crime offenses. Crimes were separated into violent and non-violent. Violent crime consisted of homicide, rape, aggravated assault, kidnapping, robbery and arson with all remaining crimes identified as non-violent, including motor vehicle theft, fraud, prostitution, driving under the influence and drug related incidents. Geographic locations of each crime incident were plotted and the counts of crime incidents within each participant’s home and work buffer were summed to provide a measure of neighborhood crime.Our first aim is to assess the impact of the LRT line opening on clinical health outcomes, health care utilization, and health care costs from three years before to three years after the line opened. These analyses include participants in the overall cohort who have at least four outcome measures over the entire six-year period, with at least one of each measure occurring prior to and after the LRT line opening.Multilevel modeling will be used to determine the effect of the LRT line opening on clinical health measures – including blood pressure, BMI, blood lipids, and HbgA1c. Time will form the first level of the model and all available measurements for each participant will be included. Person will form the second level of the model that will include person-level covariates of age, sex, and comorbid conditions measured at the earliest available time point. Since people are nested within block group, block group will form the third level of the model with a dummy variable for case versus control block group. This model will estimate a trajectory of the outcomes over time for each participant and will examine differences in trajectory based on case or control status.Segmented regression analysis will be used to compare trends in health care utilization and costs for case and control groups before and after the LRT line opening. Ultimately, this method allows us to statistically assess how much the introduction of the LRT line changed health care utilization and cost immediately and over time; transiently or persistently; and instantly or with delay. Specifically, we will perform a basic segmented regression analysis in which the overall six-year time period is divided into pre- and post-intervention segments. For each segment, separate intercepts and slopes will be estimated, thus allowing for statistical tests of changes in intercepts and slopes pre- to post-intervention. Statistical power will be enhanced if we find stable pre-intervention trends in the dependent variable of interest. We will use month as the unit of analysis (36 months pre- and 36 months post-LRT introduction). Health care utilization and cost measures will include average monthly outpatient visits and costs, average monthly inpatient length of stays and cost, average total monthly medication cost, and average total monthly health care expenditures.Structural equation modeling (SEM) will be used to determine the degree to which changes in clinical outcomes and health care costs are mediated by changes in total and transportation-associated PA , when controlling for built environment measures such as walkability and measures of pedestrian and recreational infrastructure. SEM allows us to test the relationships among the variables simultaneously. To accomplish this, change scores from the first time point (2–3 years prior to the opening of the LRT line) to the last time point (2–3 years after the opening) for all variables will be examined. To test for mediation, a multilevel structural equation modeling approach will be used. Potential moderators of the effect of the new rail line on health outcomes will also be explored. For example, the interaction between case or control status and variables such as age, sex, race/ethnicity, distance from home to station, baseline walkability, pedestrian network (as measured by the MAPS tool), and baseline functional status will be incorporated into multilevel models to test if the degree of impact of the new rail lines varies across the levels of these potential moderator variables.The sample size for this natural experiment was fixed and determined by the number of KPNW members who had residential addresses in census block groups within a 1.5-km road network buffer of one of the new LRT stations. These cases were matched at the block group level to an equivalent number of members living outside of a 1.5-km road network buffer of any existing rail station. During the planning phase of the study, the population anticipated to have sufficient data for our clinical outcomes – based on estimated variations in the data capture of clinical health outcome measurement and loss to follow-up – was 3050 participants for BMI and blood pressure; 2350 for blood lipids; and 850 for HbgA1c. The detectable changes between cases and controls for the main outcome measures were calculated with statistical power of 0.80 and an alpha level of 0.05. The calculations of detectable differential change used means and standard deviations for the outcome measures as estimates of the baseline values, accounted for the correlation between individuals nested within block groups, and assumed no change in the control group. Given these parameters, we estimated that our study would detect significant differences between cases and controls if the change over time in the light rail group was 4% greater for BMI, 1.4% greater for BP, 2.8% greater for HgbA1c, and 2.4% greater for non-HDL cholesterol. These levels would be clinically significant at the population level.For our analysis of healthcare costs, interrupted time series analyses are considered to have good statistical power if the trend prior to the system change is fairly stable. Similar segmented regression analyses have had adequate power to detect modest effects and were used to inform policy at the system level using data for 12 time points pre- and post-intervention. , 71 Our Recent cross-sectional evidence makes clear connections between built environment, activity patterns, and health outcomes; increasing levels of transit access and walkability are associated with increased physical activity and reduced levels of chronic disease.  These fiThe methods we describe constitute a unique research design to better understand the potential causal impacts of transportation investments and land use on physical activity, obesity, and clinically assessed health outcomes and cost. The ability to connect multi-billion-dollar transportation investments with similarly-scaled, currently externalized health care costs holds considerable research promise. The results from this study and others that may build on it could have a major influence on transportation investment decision-making protocols. Cost-benefit tools currently used to justify transportation investments do not account for the health impacts and costs they incur, resulting in decisions that promote roadway improvements over transit and non-motorized investments. Internalizing these costs within the transportation investment process has the potential to better estimate the collective societal impacts of these major investments.Sedentary and active travel choices are made based on the quality, convenience, and relative utility of available travel options. , 75 It cThe Rails & Health study will provide information that documents how a new transportation option can alter PA, health, and health care costs over time. This study will provide valuable data and contribute unique methods. It may also present a compelling rationale for cost benefit-tools and empirically grounded health impact assessments. These approaches can collectively assess health outcomes and costs stemming from contrasting transportation investment and land development options.


City-based organizations and governments play an important role in incorporating undocumented immigrant youth. This article investigates how localities socio-politically incorporate these immigrants by examining the governance constellations and institutional logics of the organizational field that manages undocumented youth. Comparing sets of municipal and civil society organizations in different national settings, I use the two cases of New York City and Paris to ask how the ‘city-based organizational field of immigrant incorporation’ shapes citizenship experiences of undocumented youth. Data come from multi-level longitudinal ethnography over 8 years with two dozen undocumented youth and with organizations in each city as well as interviews with immigrant organization staff and other governance actors in New York and Paris. Organizational field dynamics in Paris provide a stronger possibility of citizenship and rights acquisition, evidence of socio-political incorporation. In contrast, New York’s robust and flexible labor market and ethnic and immigrant legitimacy offer its undocumented youth a marginalized socio-political incorporation. These findings support practice-based understandings of local governance of incorporation of undocumented youth. Nation-states remain the leading authorities that provide rights to immigrants, shaping labor market access and citizenship acquisition. Within countries, however, cities have also been able to shape the acquisition and practice of rights. For this reason, scholars have increasingly used a multi-level governance lens to represent contested divisions in powers between nation-states, regions, and localities Cortez, . Cities If we are looking to explain cities’ ability to shape the lives of undocumented youths, large cities such as Paris and New York, with substantial civil societies, would be expected to be best-case scenarios. The embeddedness of each within a national system of government would be expected to shape its influence over immigration practices. Amongst industrialized countries, for example, the US has a weak social welfare system, a loosely-regulated labor market, and a federal government. One would expect a city like New York to exert much authority over the acquisition and practice of rights. Conversely, given the stronger social welfare system and centralized government in France, one would expect that undocumented youths in Paris would not be able to legalize: the costs to the state are much higher than in the US and the state has more control. Surprisingly, undocumented youths are more likely to legalize and gain the associated rights in Paris than in New York. The local interplay of civil society and government explains this unanticipated effect of local context.Given the salience of legal status to social, economic, and political opportunities, undocumented youth are particularly sensitive to local policies and practices. Local governments’ role in incorporation can vary considerably Garbaye, . By contDrawing on longitudinal data collection from two multi-level case studies with undocumented youth and organizations in New York City and Paris, I argue the interplay of state, market, and civil society actors within the local organizational field, more than formal political representation, shapes qualitatively different experiences of citizenship. Two aspects of this local governance of immigrants, governance constellations and institutional logics, shed light on how citizenship outcomes for undocumented youth differ from national models. I present a brief background on the cases of Paris and New York. The findings describe the institutionalized relationships between government and civil society, with a focus on how civil society shapes transaction costs for the government, and the resulting production of citizenship. The socioeconomic incorporation follows what might be expected from national models (e.g. looser labor market regulation in the US facilitates labor participation). In contrast, the New York organizational field produces exclusion along a socio-political axis for undocumented youth while its counterpart in Paris results in undocumented youth socio-political incorporation albeit qua ethnic minorities.This analysis engages governance and citizenship to examine obverse facets of a similar social process, immigrant incorporation. The complexities of governing migration have given rise to local initiatives, public-private partnerships, and new relationships between international, national, regional, and local actors. Many actors, those that activate citizenship from above and those that mobilize participation from below, shape how different immigrant groups integrate into the local social and political fabric. Governance, which recognizes these multiple actors, refers to “the rules of collective decision-making in settings where there are a plurality of actors or organizations” without a formal control system  incorporation and respond to field-level contingencies   and enact (reproduce) the logics of a field’” , these cities’ organizational fields produce different outcomes for their undocumented youth. This article seeks to explain this empirical puzzle by examining these organizational fields, especially the nature of links between immigrant organizations and local government. This emergent constellation of actors influences immigrant incorporation according to certain institutional logics, resulting in specific kinds of opportunities for outsider groups like undocumented youth. New York City’s more cooperation-oriented organizational field allows a laissez-faire, informal inclusion for undocumented youth. The legitimate citizen-based modes of civil society-government contestation in Paris have created an important niche opening in visa acquisition. Undocumented youth include those who entered a country as a minor without inspection by customs officials, overstayed a temporary visa, or lost a legal residence status (e.g. asylum-seekers). Residing without legal status in France and the United States is an administrative or civil violation, not a criminal one.4This project collected data using longitudinal ethnography in Paris and New York with undocumented youth and organizations that support them, including analysis of relevant organizational and legal documents. Given the tendencies of organizations to have policies that are loosely coupled with practice , onto the constraints and opportunities available to my informants, an iterative process.Thus, the representation of the organizational fields (1) begins with the experiences of undocumented youth, (2) is confirmed through data collected directly from the organizations, and (3) triangulated with the media  and social media representations of organizational activity. Regular feedback loops between each of these datasets produced a representation of the most salient internal and external dynamics of organizations. With this basis in practice, this project’s approach avoids the pitfalls associated with organizational policies being decoupled or loosely coupled to practice.Nearly a quarter of Parisians and over a third of New Yorkers are immigrants (see Table citoyen (citizen) logic to make claims on the state, permitting incorporation of undocumented youth.State, civil society, and market actors play different roles in each city. In Paris, the state—embodied in the city’s Prefecture—plays a more central role than in New York. The Prefect both directs police and distributes visas. Civil society, with associations claiming specific sets of rights , maintains a more adversarial stance to make claims on the state. The state limits the institutionalization of ethnic institutions in two ways: by de-legitimizing ethnic organizing and by weakening the connection between employers and ethnic networks through labor law. Rights-based organizations coordinate around a In New York, the division of powers limits the agency of the local and state governments. Unlike in Paris, the locally-based state cannot offer legal status to undocumented youth. Instead, civil society and city and state government have cooperated to protect undocumented residents from deportation risk, creating a buffer from federal enforcement. Civil society is organized by an ethnic logic (and ethnic voting blocs), and a few organizations coordinate associations’ claims on the state. With looser federal oversight, ethnic communities and employers have an institutionalized relationship. With available low-end jobs, New York offers its undocumented youth a socioeconomic incorporation.département prefects on the other, as making and implementing French immigration and integration policy , was to change the law to allow these populations to grow up in France and to protect them from deportation. In the decade since its birth, RESF has leveraged members’ citizen standing to make human rights claims, shifting the dynamics of Paris’s COFI and facilitating undocumented youth visa acquisition.COFI actors can provide services and protections, restrict access, or change legal status of undocumented youth. Promoting a policy of non-family, ‘highly-skilled’ migration, the French legislature and Department of the Interior directives have enacted policies that make immigration and subsequent regularization more difficult , most with work permission, have increased by nearly 10% from the period 2008–2010 to 2012–2014, naturalizations in France have dropped by about half in the same time period  providing certificates to undocumented youth and their families in ‘godparenting’ ceremonies, 2) writing letters to support regularization applications, 3) participating in protests, 4) speaking at RESF events, and 5) providing an undocumented youth contract to protect them against deportation. Youth use the resulting documents as proof of social integration when they apply for regularization.In contrast to civil society organizations that are subcontracted by the government . Unless charged with specific ‘serious’ felonies, local police do not cross-check undocumented residents’ data with federal databases when arrested, preventing possible deportations. In a context of sharply increased deportation policy under Presidents Bush and Obama, the impact of these policies should not be understated.In addition to these protections from deportation, New York has expanded its integration programs. Intended to promote and coordinate immigrant organizations and businesses in interactions with the city, the Mayor’s Office of Immigrant Affairs has grown in scope and is now considered a national leader in immigrant inclusion. Two initiatives seek to legitimize undocumented youth through identification. The City Council allocated $19 million to immigrant organizations towards outreach for the DACA program. In 2015, the City Council passed a municipal ID card program to ease undocumented residents’ lack of US-based formal documents. A liberal language policy offers city documents in the top six languages of immigrants ; they have not been a setting for mobilization, however. Furthermore, this inclusion terminates with high school. At Ernie’s high school, teachers and guidance counselors did not know about options for undocumented students and did not offer advice for post-secondary plans. The City University of New York (CUNY), a large multi-campus public university with a large immigrant student body, has targeted outreach to increase admission of Mexican students, a group with a high percentage of undocumented residents Smith, . CUNY CiLegal exclusion thus coalesces for undocumented youth around the challenges of paying for college without financial aid and finding a job outside of federal regulations. In contrast, DACA allows most undocumented youth to find work in regulated sectors. Government and civil society actors could support recruitment of DACAmented New Yorkers to CUNY. Financial aid for college would mitigate this exclusion but popular support in New York City or State has not been sufficient for legislation; some private sources now offer selective scholarships to undocumented students.While many undocumented youths pointedly feel the exclusion from obstructed access to college, other city actors value their presence. With partisan politics largely an afterthought in New York, organizational-level logics also strengthen this government-civil society consensus. Unions and religious organizations see potential members; employers desire large numbers of low-wage accommodating workers; progressives value their potential inclusion; libertarians like the lack of federal interference. While this portrait of support seems to offer many potential strategic openings, political support requires momentum. Coordinating the above interest groups would require benefits to outweigh costs for all actors and long-term benefits must remain clear  including one who became a citizen, and three remained without visa. The process of applying for a visa necessitated youth to participate socially in new ways, including bureaucratic experiences. My informants faced a particular and exaggerated version of the labor market woes faced by French youths and immigrants in general. Chen, for example, expects to gain a 10-year visa but his vision of work opportunities remains limited. Such difficulties in the labor market give undocumented (or recently documented) youth a sense of exclusion, unable to provide reliable wages to their needy households or even to facilitate romantic relationships. Chen’s Chinese background does not connect to French discourse or civil society the way that being a Mexican or Latino immigrant in New York gives Ernie a foothold into an American identity and civil society. Thus, even after gaining legal status and its accompanying social rights, youth in Paris fail to develop a well-rooted sense of belonging.By 2016, one New York informant had moved back to Mexico, one had gained a green card using a limited loophole, community organizations helped seven to successfully apply for DACA (one did not renew), and three did not apply. Without the benefits of formal citizenship, New York youth experience a socioeconomic incorporation albeit one in a subordinate position. Like Ernie, most of my New York informants work for low wages in no-growth but full-time jobs in restaurant kitchens, delis, construction, and factories. This outcome stems from the looser labor market and job entry facilitated by strong ethnic networks. Exceptional are two informants with college experience who have leveraged DACA benefits to work in a community organization and a research lab; they also are the only ones who have participated in the Dreamer movement. Undocumented and DACAmented youth felt symbolically included and contributed to society through work and family, they sensed their socioeconomic marginalization as they see their peers more smoothly attained postsecondary experience and better jobs with less exploitation. The buffer from federal restriction let youth experience everyday inclusion, from using New York’s public transportation and visiting Times Square to joining sport leagues. This opening and the availability of stable low-paying jobs, however, provided necessary resources and built a sense of belonging in undocumented male youth and their working-poor families.Local governance shapes immigrants’ citizenship possibilities (Dekker et al., Findings, based on multilevel longitudinal ethnographic data, showed surprising socio-political outcomes in Paris and New York. Cities articulate some similar goals of immigrant incorporation but end with different results given different sets of actors working with different institutional logics. Immigrants surely represent themselves in both organizations and government to a greater extent in New York than Paris. The fragmented division of powers, strategic alliances, and contentious citizen-based claims, however, favor the legalization chances of undocumented youth in Paris. Despite political underrepresentation in each city, organizations use logics of democratic legitimacy, public order, and market efficiency to institutionalize social movements into governance actors. The strategic opening exploited by Paris civil society actor RESF responds to a discourse of assimilative citizenship (Nicholls, When interpreting the effects of the COFI on undocumented youth, we can see nuance in incorporation outcomes. The local actors in Paris and New York filter France’s civic assimilative model and the US pluralist model, following much more contextualized logics than we would expect of either of these models. For undocumented youths, socio-political inclusion is easier to achieve in Paris than New York. In Paris, social movement tactics combine with local social policy to gain a foothold for undocumented youth. In New York, Civil Rights Era-influenced ethnic politics convince organized interests to support them.Studies have shown how local governance actors shape cultural integration (e.g., Penninx et al., Rather than focusing on policy alone, this article shows how the practices of—and between—government, civil society, and market actors in the COFI shape uneven lived citizenship experiences of undocumented youth as they come of age. The formal right to reside, more easily attained in Paris, does not necessarily equate with participation or a sense of belonging. Marginalization in New York did not preclude participation or a sense of belonging. Although undocumented residents are often portrayed as outside the system—“un-citizens” in the words of one scholar Nash, , this lo