In March 2017, the Second Interventions in Aging Conference was held in Cancun, Mexico and organized by Fusion Conferences, Ltd. As meeting organizers, we would like to provide a brief overview of the meeting proceedings, which reflect larger views in the aging research field about the future directions critical for continued progress.The meeting, similar to the earlier event in 2015, was focused on interventional strategies. One notable difference was that this year's meeting was much more directed toward potential interventions to target human aging. The field has been very successful over the last decade in identifying interventions that extend lifespan and healthspan in animal models such as yeast, flies, worms, mice and, to some extent, primates. However, the primary goal is to employ knowledge from basic aging research to develop novel medical strategies aimed at extending human healthspan. Aging is the biggest risk factor for a wide range of chronic diseases that, to date, medical strategies have treated as separate entities, and as they arise. Yet, aging is driven by a limited number of coordinated pathways that can be modulated, and evidence suggests that interventions delaying aging will protect against multiple age-related diseases simultaneously [Organismal Aging, or understanding the intrinsic pathways that govern aging of the entire organism. Platform presentations were provided by Rozalyn Anderson (University of Wisconsin-Madison), Adam Antebi , Holly Brown-Borg (University of North Dakota), Yuki Ikeno and Nicolas Musi , Laura Niedernhofer (Scripps Florida), Scott Pletcher (University of Michigan), Eline Slagboom . The interesting aspect of these presentations is that they address strategies to modify aging that touch back to research from the early days of aging research while simultaneously pointing to novel strategies for future interventions. Dr. Brown-Borg defined new mechanisms linking growth hormone signaling to aging, Dr. Ikeno, using mammalian models, re-evaluated the role of reactive oxygen species; Dr. Niedernhofer presented new evidence for links between progeria and normal aging, interpreting these strategies in the context of possible interventions that may affect both normal and “premature” aging; Dr. Musi linked NFKB signaling to sarcopenia, a major driver of frailty in aging; Dr. Pletcher described fly studies to examine the impacts of psychological stress on aging using flies; Dr. Antebi discussed novel strategies linking nuclear structure to aging using the classic model organism – C. elegans; Dr. Anderson elaborated mechanisms linking calorie restriction to lifespan extension in primates; and Dr. Slagboom described strategies to examine the impact of aging pathways in elderly human populations.There were seven research topics each addressed thematically at the meeting. All were chosen because they embody different strategies to target human aging. Each session combined talks from Platform speakers with those chosen from submitted abstracts. The first and largest theme was targeted toward Stem Cells to target aging, with exciting presentations by Heinrich Jasper (Buck Institute for Research on Aging) on aging of epithelial stem cells in flies and mice, Emmanuelle Passague (Columbia University) on links between metabolism, autophagy and aging in the hematopoietic system and Sara Wickstrom , who discussed focused on how adult stem cells self-organize into functional configurations. The third theme, addressing Cellular Mechanisms of Longevity Assurance, focused on pathways suspected to modulate aging, including autophagy by Malene Hansen , mitochondrial function and aging with emphasis on the role of small mitochondrial peptides by David Lee , and the hypoxia pathway by Dana Miller (University of Washington).The second theme was focused on using Epigenetics, which is not only becoming a target for intervention in aging, but is rapidly becoming a leading candidate for providing biomarkers of biological age. Weiwei Dang (Baylor College of Medicine) studied mesenchymal stems cells and adipocyte differentiation, elucidating mechanisms leading to activation of the protein deacetylase, SIRT1; Dr. Eric Greer  evaluated mechanisms leading to transgenerational inheritance of epigenetic marks that impact lifespan, John Sedivy (Brown University) described links between the epigenome and activation of somatic retrotransposons, and how this activation may drive senescence and aging; and Steve Horvath (UCLA) detailed a number of studies further promoting the epigenetic clock as a marker of accelerated and delayed aging.Theme 4 centered on Systems Aging viewpoint. Such a holistic understanding of the aging process is in a sense the ultimate goal of the research. Is it possible to understand such a complex process as aging not just one gene and pathway at a time but in totality? Anne Brunet (Stanford University) discussed strategies to model aging using worms and killifish (a short-live vertebrate gaining popularity in the aging research field); Paul Robbins (Sripps Florida) described studies to target mammalian aging and Christiaan Leeuwenburgh (University of Florida) described the multi-fold connections between iron metabolism/transport and aging. The final theme centered on Signaling and Metabolism, hitting the major metabolic pathways that are linked to aging and that can be targeted with interventional strategies. These include the mTOR pathway and rapalogs, discussed by Matt Kaeberlein (University of Washington); dietary restriction and links through mTOR to regulation of mRNA splicing, discussed by William Mair (Harvard University), dietary restriction in primates discussed by Julie Mattison , NAD metabolism and Sirtuins, discussed by David Sinclair  and mitochondrial roles in regulating aging and metabolism, discussed by Pinchas Cohen (USC Leonard Davis School of Gerontology).Theme 5 was designed to take a rd Interventions in Conference to be held in approximately two years.As we move closer to interventions targeting human aging, it is critical to get together and discuss the best strategies and the ideal path forward. The meeting in Cancun provided a low stress atmosphere where scientists in the aging field could not only share data but take the time to think creatively and discuss issues in depth. We as organizers thank the session chairs, speakers, poster presenters and attendees, as well as the staff of Fusion Conferences, Ltd. for enabling a fascinating meeting. We also look forward to the 3The Second Interventions in Aging Conference was organized by Fusion Conferences, Ltd.www.aging-us.com).The Second Interventions in Aging Conference was sponsored by Aging (Aging is published by Impact Journals, LLC.


The Social Mobilization Network (SMNet) has been lauded as one of the most successsful community engagement strategies in public health for its role in polio elimination in India. The UNICEF-managed SMNet was created as a strategy to eradicate polio by engaging >7000 frontline social mobilizers to advocate for vaccination in some of the most underserved, marginalized, and at-risk communities in India. This network focused initially on generating demand for polio vaccination but later expanded its messaging to promote routine immunization and other health and sanitation interventions related to maternal and children’s health. As an impact of the network’s interventions, in collaboration with other eradication efforts, these high-risk pockets witnessed an increase in full routine immunization coverage. The experience of the SMNet offers lessons for health-system strengthening for social mobilization and promoting positive health behaviors for other priority health programs like the Universal Immunization Program. Polio eradication efforts in India and globally have demonstrated that, in many locations, the critical path to success lies in complementing a focus on biological issues with a comprehensive address of the sociocultural challenges . ExperieIndia’s last polio case occurred on 13 January 2011, and the country was certified polio free in 2014, after many years of concerted efforts led by the government of India with ardent support from partners, including the World Health Organization (WHO), UNICEF, and Rotary. In an effort to eradicate polio, the world’s largest coordinated vaccination campaigns were launched, with millions of frontline workers vaccinating 170 million children aged <5 years in each national polio round , 9. A maThe SMNet originated due to a need to interpret and engage the role of social determinants in the transmission and outbreak of wild poliovirus in these states. At the time, Uttar Pradesh—India’s most populous state, with poor sanitation and hygiene, a high enteric disease burden, high population density, and a large birth cohort—offered favorable conditions for poliovirus to spread and, as a result, regularly recorded the highest volume of polio cases in the world . VaccinaThe SMNet was tasked with identifying and engaging with these high-risk groups in high-risk areas to ensure all children aged <5 years were vaccinated against polio in every round. As part of the 107 Block Plan, the network introduced convergent messaging promoting routine immunization, diarrhea prevention and management, handwashing with soap, and exclusive breastfeeding practices as a means to both tackle underlying causes for ongoing polio transmission and alleviate resistance by holistically addressing concerns of underserved populations.As part of the Polio Endgame Strategy, the SMNet increasingly focused on boosting full immunization through engaging policy, strengthening capacity development, and monitoring for communication activities, social mobilization, media sensitization, supportive supervision, and evidence-based, real-time communication planning.This article describes the key strategies of the SMNet, which were designed to support polio eradication and have since been applied to routine immunization and broader health system strengthening in India. The network developed and demonstrated key strategies such as evidence-based communication planning and microplanning, development and maintenance of interpersonal communication skills for mobilization of individuals and groups, strong outreach and advocacy, systematic building of an effective partnership for communication and strong supervision, and accountability for action . These sThe SMNet’s success was built on a strong polio partnership with multiple stakeholders, such as tgovernment agencies; development partners, including WHO, Rotary, and CORE group and local community-based institutions.  Government partners included the Department of Women and Child Development, Rural Development Department, National Cadet Corps, Indian Railways, and paramilitary forces. A seamless partnership with the WHO–National Polio Surveillance Program helped in joint microplanning, monitoring and supportive supervision practices, and the development of various training resources for training and capacity building of health functionaries. The Indian Medical Association, India Academy of Pediatrics, and several universities also played important roles in supporting the program.panchayat raj originated during the British administration. Raj literally means governance or government.) District and block officials were responsible for overseeing task forces and evening meetings, which triggered corrective action both daily and strategically to ensure continually improving, high-quality campaigns.A core strategy of the program was to engage leaders at all levels, especially local and national levels. Perhaps more important, the local officials (Panchayat Raj Institutions) were involved in mobilizing their communities- building “polio gates,” inaugurating booths/campaigns and ensuring proper visibility of materials. , refresher training (3 months after joining), and annual interpersonal communication training. Several forms of informal trainings were conducted, with particular emphasis on supportive supervision visits where the SMNet was working. At all levels, a culture was developed where the identification of areas of programmatic weakness and capacity/knowledge gaps was considered good practice and rewarded. These trainings also contributed toward capacity building and skill development of frontline workers such as Accredited Social Health Activists, Anganwadi Workers, and Auxiliary Nurse Midwives, particularly in Bihar, where these cohorts were systematically engaged ahead of all campaigns. , the SMNet systematically tracked >2000 sites with highly mobile and migrant group traffic, covering 83000 families (61000 children aged <5) that were left out in earlier rounds.The 3-tiered structure of the SMNet galvanizes social mobilization and communication for behavior change at the district, block, and community level via District, Block and Community Mobilization Coordinators in areas where demand and service delivery is poor. The SMNet uses a multipronged communications approach encompassing (1) mass and mid-media approaches ; (2) information, education, and communication materials; (3) ground-level community engagement strategy engaging community influencers, religious leaders, house-to-house mobilization, and mothers meetings; and (4) the use of key community sites such as mosques, schools, or religious festivals to generate demand.The CMCs of the SMNet are overwhelmingly women aged 25–45 years with basic literacy skills and are responsible for 350–500 households. They are drawn from the same community where they work and have the same religious beliefs and language/ dialect. They support the Universal Immunization Program by mobilizing communities through house-to-house interpersonal communication and group counselling sessions addressing myths and misconceptions and ensuring correct knowledge about vaccines. The CMCs mobilize families, hold mothers’ meetings and religious meetings, coordinate mosque announcements, and conduct polio classes in schools, madrasas, and other congregations. Each month, the network holds >7000 mothers’ meetings and >200000 individual interpersonal communication sessions for routine immunization , reaching out to approximately 2.53 million households to inform parents of the timing and location of upcoming sessions and if and when their children are due for vaccination. On the day of the Universal Immunization Program session, the CMCs are required to be present at the session site, working from a checklist that monitors whether the vaccinator is in attendance; whether all vaccines and other hardware, including needles and sharp boxes, have been supplied; and whether caregivers have been informed about the date of their next required immunization for their child and the risks of adverse events following immunization. These monitoring forms are then referred by the Block and District Mobilization Coordinators to the district authorities for real-time feedback and corrective actions. Community Mobilization Coordinators use the opportunity of the session site to further counsel the community on diarrheal control , exclusive breastfeeding, hand washing, and toilet use/conversion).A systematic media engagement strategy was used in high-risk states, supported by human resources capacity at the national and state levels within UNICEF. This strategy used regular media workshops for electronic and print media and facilitated field visits, briefings, and campaign launches to improve the quality and tonality of reporting and to create a supportive media environment, which played a key role in reaching out to high-risk populations. Appeals from political and religious leaders in the print media and the use of local channels to answer localized rumors also helped to build faith in vaccines.  immunization reporting system, (2) concurrent monitoring (both operations and communication) and supportive supervision, and (3) evaluation studies such as Knowledge, Attitude, and Practice (KAP) studies and SMNet evaluations. The main feature of the SMNet monitoring system was the capacity for real-time analysis of collected data and feedback every night during campaigns (for in-course corrective action) and for analysis prior to monthly campaign review and preparation meetings. This enabled the SMNet functionaries to identify issues for targeted response , as well as to track individual performance and take corrective actions if targets were not being achieved or significant deviations were evident.Following the “end” of polio in India, UNICEF’s SMNet has been used by the government of India for monitoring of communication activities related to Mission Indradhanush, the immunization campaign. UNICEF helped to develop a new monitoring tool to collect data from >1000 monitors (which included the senior cadres of the SMNet who had been relocated to support poor-performing routine immunization states) to generate a dashboard for the government to take immediate corrective actions during the campaign. This resulted in improvement of communication indicators and coverage during successive Mission Indradhanush campaigns.A national campaign to boost routine immunization in poor-performing states and districts was launched in 2015 and used some strategies developed by the polio program to boost full immunization, particularly in high-risk areas and groups. More than 500 SMNet members were deployed from Bihar and Uttar Pradesh across 52 districts of non-SMNet high-priority states like Madhya Pradesh, Rajasthan, Haryana, and Chhattisgarh to augment the communication activities for demand generation in these states, supporting communication planning, implementation, advocacy, social mobilization, monitoring, and supportive supervision. More than 200 additional members were deployed within the SMNet states of Uttar Pradesh and Bihar to non-SMNet areas to support communication activities under Mission Indradhanush, focused on coaching local officials and frontline workers on strategies to effectively campaign to reach every child. Through SMNet support and effective monitoring of communication activities, district communication plans were updated in 94% of deployed districts  . Various studies have documented the SMNet’s contribution toward strengthening supplementary and routine immunization activities . With thA large proportion of inequities in routine immunization coverage and health delivery can be attributed to inequalities in social determinants . EvidencSMNet, which evolved as a program communication network as part of the polio eradication strategy, developed and displayed some key strengths that can be used for other programs that depend on community orientation for better uptake of services, especially in underserved and marginalized communities. The network developed and displayed key strengths in terms of strong outreach and advocacy, highly skilled interpersonal communication both for individuals and groups, effective partnership leveraging, media management, and evidence-based planning. In addition, the program offers lessons in terms of robust program management systems, including communication planning, capacity building, and monitoring and supportive supervision systems.These key lessons learned and human resources of the SMNet have the potential to be used for other government health goals and priorities, such as Reproductive, Maternal, Newborn, Child, and Adolescent Health (RMNCH+A) activities and the Global Action Plan for the Prevention and Control of Pneumonia and Diarrhea, especially in high-risk and hard-to-reach areas . (The RMIn sum, the strategies of the SMNet are replicable, proven approaches for health promotion and health-system strengthening, especially for the Universal Immunization Program, and to ensure the equity of health delivery in underserved or difficult-to-access areas. The SMNet itself remains a valuable human resource—well trained and accepted by the community—that can immediately be used for other child health initiatives and, in particular, for “reaching the unreached” with the Universal Immunization Program or broader health initiatives.


Accountability for ensuring sexual and reproductive health and rights is increasingly receiving global attention. Less attention has been paid to accountability mechanisms for sexual and reproductive health and rights at national and sub-national level, the focus of this systematic review.We searched for peer-reviewed literature using accountability, sexual and reproductive health, human rights and accountability instrument search terms across three electronic databases, covering public health, social sciences and legal studies. The search yielded 1906 articles, 40 of which met the inclusion and exclusion criteria  defined by a peer reviewed protocol.Studies were analyzed thematically and through frequencies where appropriate. They were drawn from 41 low- and middle-income countries, with just over half of the publications from the public health literature, 13 from legal studies and the remaining six from social science literature. Accountability was discussed in five health areas: maternal, neonatal and child health services, HIV services, gender-based violence, lesbian/gay/bisexual/transgender access and access to reproductive health care in general. We identified three main groupings of accountability strategies: performance, social and legal accountability.The review identified an increasing trend in the publication of accountability initiatives in Sexual and Reproductive Health and Rights (SRHR). The review points towards a complex ‘accountability ecosystem’ with multiple actors with a range of roles, responsibilities and interactions across levels from the transnational to the local. These accountability strategies are not mutually exclusive, but they do change the terms of engagement between the actors involved. The publications provide little insight on the connections between these accountability strategies and on the contextual conditions for the successful implementation of the accountability interventions. Obtaining a more nuanced understanding of various underpinnings of a successful approach to accountability at national and sub national levels is essential. Accountability has long been a key theme in international development and its related disciplines –2. For hRecently, accountability in health has become a key priority at the highest levels of the United Nations system through its engagement with national governments. The Commission on Information and Accountability for Women’s and Children’s Health (CoIA), founded in 2010 as a follow-up to the UN Secretary General’s initiative “Every Woman, Every Child”, recommended that all countries establish and strengthen accountability mechanisms that are transparent and inclusive of all stakeholders . This waDespite increased attention to and demand for accountability in health from multiple and varied global stakeholders, understanding of accountability initiatives for sexual and reproductive health at national and sub-national levels remains limited. Given the multi-disciplinary contributions to understanding accountability, we undertook a systematic review of peer-reviewed literature across disciplinary boundaries. Considering this complexity, at an initial stage in our systematic review, we sought to map the range of accountability strategies and instruments used to address sexual and reproductive health and rights, the low and middle-income contexts in which they were implemented and the resulting documented outcomes.In the paper, we use the terms “accountability strategy”, “accountability intervention”, “accountability instrument” and “accountability mechanisms”.An “accountability strategy” is any overarching set of programmes and activities, conducted by governments, non-governmental organizations (NGOs), grassroots organizations, activist lawyers as well as communities with the intention to enforce or support accountability.The term “accountability intervention” refers more narrowly to the operational level. Examples include setting up a village health committee, bringing a court case or carrying out a drama workshop to educate villagers on sexual and reproductive health rights (SRHR). Interventions are usually delivered within projects or programmes with the objective of supporting accountability.An “accountability instrument” is the use of particular implementation tools within the context of a given intervention. Examples include patient charter rights or digital health feedback applications.An “accountability mechanism” is a theoretical explanation of why a strategy or intervention works. Explanatory theoretical mechanisms include collective action, community empowerment, transparency, and enforcement.The review methodology was initially structured with a realist and multi-disciplinary intent to ask “what works in terms of accountability mechanisms in the field of sexual and reproductive health rights (SRHR) at sub-national and national levels, how, why and in which context?”. The review is based on a protocol that was reviewed by an international expert technical committee. We were guided by a meta-interpretation approach , which mTo capture the accountability strategies across multiple disciplines, we used three search engines: PubMed , Web of Knowledge  and LexisNexis Academic (law). The search terms included combinations of free-text words in TI and /or all fields, depending on the search strategies allowed by the database in question . We refeOptions to select languages other than English were limited in the three databases. In LexisNexis Academic, two categories of law reviews were available to cover different languages: (1) UK and European journals and (2) Brazilian, Asian law and French language journals and reviews. The UK/European law journals also include journals on legal traditions from LMIC, e.g. Journal of African Law and the Journal of Asian Law. No specific language or country selection options could be made in PubMed and Web of Science.Each abstract was screened using the inclusion and exclusion criteria presented in The abstracts that met the inclusion criteria  were then reviewed to assess if they (1) relate to any accountability strategy or mechanism, (2) relate to a SRHR area or (3) a national level judicial or reconciliation mechanism . The latter included studies reviewing jurisprudence from supreme, constitutional or other national and provincial level courts. To verify fidelity to the inclusion criteria, a sample of 20 abstracts per database were checked for inclusion/exclusion by a second senior researcher. Two researchers discussed the papers for which they had a different opinion until a consensus was reached.After the full text review, articles were further excluded based on the exclusion criteria . We present the papers that were included in The review question guided the data extraction. Categories included in the data extraction include: (1) author; (2) SRHR issue; (3) year of publication; (4) number of citations (Google Scholar); (5) year of intervention; (6) original language; (7) funding source; (8) study setting; (9) type of study; (10) accountability type according to the article or as deduced by the researcher; (11) accountability relationship (from whom to whom); (12) accountability strategy and implementation instrument; (13) level at which strategy is supposed to work; (14) purpose (why?); (15) lessons learned; (16) reported outcomes; (17) mechanisms; (18) equity effects; (19) description of the intervention or action; (20) scale of the intervention or action; (21) target population and finally (22) the actors involved in the accountability strategy.Since this review covers several disciplines  with different disciplinary standards for writing and quality appraisal, it is difficult to apply a single framework to assess quality across the cases. Legal reviews, for instance, apply a critical (post-positivist) paradigm and typically do not provide a methodology section. Other studies included do not neatly distinguish between reporting and interpreting results. To gauge quality across the papers, we applied the principles of data quality appraisal for qualitative research  and usedNarrative synthesis  was usedA total of 1,906 articles were found when the search terms were applied to the three databases. On application of the inclusion and exclusion criteria, 1,631 abstracts were excluded. Further review of the 275 included abstracts led to sixty articles downloaded for a full-text review: 18 articles were retained from Web of Science, 20 articles from LexisNexis Academic, and 22 from PubMed. The articles came from public health, legal studies, political science, history, social psychology, anthropology, critical theory, ethics, health services management, clinical sciences, public administration, conflict studies, transitional and restorative justice studies, development and humanitarian studies. This underscores the need for an interdisciplinary approach to understand and examine the different aspects related to accountability in health. After the full text review, twenty out of sixty articles were further excluded resulting in the final selection of 40 articles documenting experiences related to accountability for SRHR at national and subnational level in low and middle-income countries between 1994–2016 .Of the 41 low- and middle-income countries featured, eighteen articles reported on cases in sub-Saharan Africa, 10 in Latin America, nine in Asia, three in the Middle East/Maghreb and one in Europe. Several countries were represented in multiple articles: India (6 studies), South Africa (5 studies), Nigeria (3 articles) and Guatemala (2 studies). Seven studies were in humanitarian or post-conflict settings . Nine articles reported on multi-country interventions or used examples from more than one country.While the search period ran between 1994 and October 2016, the majority of articles were published between 2014 and 2015. A range of disciplines and study designs are included . Just ovIn terms of study quality, we found that eighteen papers presented an audit trail, 15 had a sampling process described, and in 15 papers, triangulation, member checking or deviant case analysis was used to ascertain validity. Fourteen out of 40 studies (35%) obtained the highest score for explanatory power, only 6 (15%) obtained the highest score for insider comprehensiveness, 13  did so for the advancement of knowledge and 5 out of 40 studies (12.5%) for detail (i.e. making the study clear for outsiders) see . EighteeWe found that that five areas of SRHR were discussed: maternal, neonatal and child health services, HIV services, gender-based violence, LGBT access and access to reproductive health care in general .In the 40 studies reviewed, we identified three main groupings of accountability strategies: performance accountability, social or ‘community’ accountability and legal accountability. Performance accountability mainly refers to the internal systems that governments hold service providers and health systems to account , VRSC, surveillance, etc.), while social accountability is about citizens holding service providers to account. Articles on both of these types predominantly focused on improving the quality of maternal, neonatal and child health care, and increasing coverage and service utilization.performance accountability and they increase in number from 2012 onwards [Fifteen of the publications deal with  onwards –35, 56.  onwards , 56.Social or “community” accountability is examined by nine articles. These studies sought to bolster the capacity of communities to demand improved service delivery and provider responsiveness through raising community awareness and voice [nd voice , 51, 57.nd voice , 25 in tnd voice . Among tlegal accountability for SRHR . Broadly speaking, legal accountability is about holding the government accountable to wronged citizens and communities. These studies include investigations of accountability achieved through national legal systems, i.e. strategic or public litigation and tribunals. We can distinguish two sub-themes: one is related to accountability for human rights violations and the second is accountability for upholding constitutional rights. The former considers the violations and (lack of) protection of sexual and reproductive health and rights under a national legal and policy framework. These studies interpret the State’s role as duty-bearer to implement national and sub-national accountability strategies to protect citizen’s economic, social and cultural rights. These tended to be examples of NGOs, both progressive and conservative ones, use of strategic litigation or public interest litigation as an instrument to enforce accountability for infringements of human rights, for example in Chile [The final thirteen articles related to in Chile , Argentiin Chile , Harayanin Chile . In the in Chile –49, 55.Furthermore, the studies related to legal accountability detailed how national policies and national legal systems increasingly play a role in delivering accountability . A numbeSeveral of articles identified particular contextual conditions associated with successfully undertaking accountability for SRHR at national and sub-national level. The studies reviewed reported several types of outcomes (See S6 Table). Not surprisingly, few studies were able to document health outcomes due to their study designs. Authors more frequently focused on intermediary outcomes, such as community or health care user empowerment, provider behaviour, broader health systems or changes in legislation, policy or guidelines changes.Hussein and Okonufua  summarizTopp et al.  and PappThree studies reported unintended effects. Topp et al.  found thWe also assessed whether the studies reported any outcomes related to increased equity. Few studies reported evidence on the equity effects of accountability strategies, though several commented on their potential to influence equity positively. For example, accountability strategies involving civil society organization’s use of strategic litigation and constitutional accountability point to their potential to enforce access for disenfranchised groups  and theiOur review confirms the rising importance of accountability initiatives in SRHR as signalled by the increase in publications in 2014 and 2015. While the bulk of the articles are drawn from public health, a significant number of articles reflect legal perspectives, as well as contributions from other social science disciplines. The public health studies were largely qualitative case studies, with very few ethnographic, action research or critical studies contributions. The quality of the studies was hard to assess given the diverse disciplinary background of the articles.The review classed the accountability articles into three main strategies: performance, social and legal accountability. While the majority of articles on performance and social accountability strategies focused on improving service delivery for maternal, neonatal and child health, legal and policy activism aimed at addressing accountability for HIV, GBV and LGBT concerns.The review confirms the emerging analytic paradigm that treats accountability interventions as situated within complex accountability ecosystems comprised of multiple actors and institutions with a range of roles, responsibilities, interactions, and incentives. These ecosystems operate at multiple levels, from the transnational to the local.These accountability strategies change the terms of engagement among the actors involved. Our review highlights that accountability is not a ‘one size fits all’ formulation where a set of prescribed tools can be transferred from one setting to another with an expectation of achieving similar outcomes. Rather, the success of accountability strategies is influenced by context-specific factors including power relations, socio-cultural dynamics, and the ability of community to negotiate accountability. Thus, our review’s finding align with analyses of accountability strategies and interventions beyond SRHR .The recommendations made by the Commission on Information and Accountability for Women’s and Children’s Health in 2011  coincideIn terms of impacts on health, the bulk of articles focused on MNCH, though several articles documented accountability experiences related to HIV, gender-based violence, LGBT or reproductive health. No published articles were found related to safe abortion, reproductive cancers or family planning, despite the active social movements and the role of litigation supporting policy and programming in those areas.In terms of specific populations, articles did reflect the experience of reproductive age women, HIV affected populations and LGBT communities. While several articles reported accountability measures for marginalized communities, the specific experiences of adolescents and sex workers were not captured by the studies reviewed. While several articles listed marginalized communities as their main concern, authors tended not to address the equity effects of the accountability strategies being assessed. No publications examined how the accountability strategies addressed structural inequalities and benefits distribution across populations.Finally, we note certain gaps in the published literature with regards to other types of accountability strategies beyond those in the three categories our review examined. The studies reviewed paid little attention to parliaments, a traditional institution for public accountability in democratic governance models; to national human rights bodies; or to the effects of elections or protest actions. We did not find studies discussing parliamentary committee works such as budget committees, nor parliamentary hearings on sexual and reproductive health and rights. Also absent were references to ombudsman and whistle-blower strategies and administrative sanctioning procedures as accountability instruments. Financial accountability, and related tools such as participatory budgeting, are also missing in the published literature for sexual and reproductive health and rights.One of the strengths of this review is that it gathered articles from diverse disciplines. This has broadened our understanding of accountability ecosystems in SRHR, and particularly of how they change the terms of engagement between the actors involved. A second strength is that the review covered not only specific interventions but also approaches such as civil society action and litigation.Arguably, this review only represents a sliver of what is happening on the ground as it was limited to the peer-reviewed literature. It therefore necessarily reflects the academic evidence base on accountability in health or other sectors. Much of the evidence related to civil society action in sexual and reproductive health and rights has not been published in peer-review journals. A wider review of accountability in the grey literature would be necessary to address the noted evidence gaps. Nevertheless, limitations will likely remain as documentation of actions by practitioners such as activist civil society organisations is often neither their priority especially given the resource constraints they often face.Another limitation is related to language: only LexisNexis Academic allowed for selection other languages than English. Finally, there may be some bias in the selection of studies retained in the review, as only 3 sets of 20 abstracts, drawn from the papers selected by each database were checked for adherence to the inclusion/exclusion by a second researcher. We acknowledge this constituted a small sample.As we note above, our review highlighted the importance of viewing accountability as located within accountability ecosystems. However, the current state of research provides little insight on how SRHR accountability strategies work as part of an accountability ecosystem and under which conditions. This gap is not specific to studies of SRHR, but is a challenge to research on accountability across sectors. We welcome the increased focus on accountability across different dimensions of health, particularly in relation to sexual and reproductive health and rights. However, policymakers and practitioners are often under pressure to identify what appear to be simple solutions, which run the risk of reducing accountability interventions to tokenism or quick fixes. A more nuanced understanding of contextual factors and their impacts on different strategies and processes and the capability of individuals and communities to negotiate accountability lies at the heart of ensuring that accountability efforts affirm sexual and reproductive health and rights.S1 Table(DOCX)Click here for additional data file.S2 Table(DOCX)Click here for additional data file.S3 Table(DOCX)Click here for additional data file.S4 Table(DOCX)Click here for additional data file.S5 Table(DOCX)Click here for additional data file.S1 File(DOC)Click here for additional data file.


Due to advances in the field of oncology, survival rates for children with cancer have improved significantly. However, these childhood cancer survivors are at a higher risk for obesity and cardiovascular diseases and for developing these conditions at an earlier age.In this paper, we describe the rationale, conceptual framework, development process, novel components, and delivery plan of a behavioral intervention program for preventing unhealthy weight gain in survivors of childhood acute lymphoblastic leukemia (ALL).A Web-based program, the Healthy Eating and Active Living (HEAL) program, was designed by a multidisciplinary team of researchers who first identified behaviors that are appropriate targets for weight management in childhood ALL survivors and subsequently developed the intervention components, following core behavioral change strategies grounded in social cognitive and self-determination theories.The Web-based HEAL curriculum has 12 weekly self-guided sessions to increase parents’ awareness of the potential impact of cancer treatment on weight and lifestyle habits and the importance of weight management in survivors’ long-term health. It empowers parents with knowledge and skills on parenting, nutrition, and physical activity to help them facilitate healthy eating and active living soon after the child completes intensive cancer treatment. Based on social cognitive theory, the program is designed to increase behavioral skills  and self-efficacy and to provide positive reinforcement to sustain behavioral change.Lifestyle interventions are a priority for preventing the early onset of obesity and cardiovascular risk factors in childhood cancer survivors. Intervention programs need to meet survivors’ targeted behavioral needs, address specific barriers, and capture a sensitive window for behavioral change. In addition, they should be convenient, cost-effective and scalable. Future studies are needed to evaluate the feasibility of introducing weight management early in cancer care and the efficacy of early weight management on survivors’ health outcomes. Dramatic improvements in the diagnosis and treatment of cancer in childhood have led to a rapidly growing cohort of survivors, now estimated to exceed 450,000 in the United States . HoweverFew interventions are designed to promote lifestyle modifications in childhood cancer survivors to reduce obesity and CVD risk . To our Although cancer treatment can directly impact weight patterns, children also develop adaptive behaviors such as poor eating habits and physical inactivity during treatment. We conducted preliminary studies that identified intake patterns and levels of total energy expenditure in young survivors of pediatric ALL and lymphoma ,12. ThesBased on these findings, we developed a Web-based weight management program, the Healthy Eating and Active Living (HEAL) program, tailored for families with patients and survivors of childhood ALL, the most common cancer in children. Here we describe the conceptual framework, development process, novel components, and delivery plan of the HEAL program.A multidisciplinary team of researchers  met weekly and identified behaviors that are appropriate targets for weight management in childhood cancer survivors and formulated the intervention components. Guided by strong evidence in childhood cancer survivors and informed by obesity prevention programs in the general pediatric population, we identified parenting, nutrition, and physical activity as 3 behaviors to change for the development of the HEAL program. Following the identification of behaviors to change, we used a basic framework of core behavioral change strategies as a foundation to formulate program goals and components. These core behavioral change strategies are grounded in theoretical models  ,28, inclParental perception of their child’s weight status is a key factor in determining parents’ readiness for weight management for their child . The curThe parenting focus is to improve parenting practices that facilitate healthy eating and active living in the family. The HEAL program engages parents as the agent of change, because the program targets on young children with ALL who largely fall into the age range of 4 to 10 years old when they start maintenance therapy or within 2 years of treatment completion. It emphasizes parents’ roles in transitioning the family toward healthy eating and active living through modifying the family environment. It also addresses common barriers that parents face in implementing change at the family level.The nutrition focus is to enhance diet quality by (1) limiting consumption of sugar-sweetened beverages (SSBs) and foods high in empty calories; (2) limiting consumption of processed foods and snacks high in sodium; and (3) increasing consumption of vegetables, fruits, and whole grains. Although not a direct target for weight management, the program also includes (4) increasing dietary sources of vitamin D and calcium.The physical activity focus is to increase activity by (1) reducing screening time, (2) gradually increasing activity to 60 or more minutes/day and incorporating physical activity into daily activities, and (3) incorporating bone-strengthening activity 3 or more days/week ,31.The HEAL program is designed to increase behavioral skills through goal-setting, self-monitoring, and problem-solving. Goal-setting uses SMART planning to help parents set Specific, Measurable, Achievable, Relevant, and Time-bound goals and action items . ParentsThe HEAL program is designed to incrementally support and increase behavioral skills. As these are developed, participants acquire mastery experiences to increase self-efficacy.The program uses positive reinforcement strategies to further promote self-efficacy by sending parents motivational messaging throughout the course of the program. The motivational messages were developed by the clinical psychologist and behavioral scientist on the research team. They serve to remind parents to set goals, track child’s food intake and physical activity, and complete self-guided curriculum sessions and to provide recognition and encouragement after parents complete these activities. Some of the messages are also designed to promote 3 basic psychological needs: competence, autonomy, and relatedness, grounded in self-determination theory (SDT). The motivational messages are sent automatically to parents’ email or through short message service (SMS) after parents enroll into the program, following predetermined algorithms based on program usage and completion status. Alternatively, motivational messages can be delivered by a lifestyle coach trained in motivational interviewing who can further provide feedback based on usage and completion. The use of a lifestyle coach as human contact to support the program is optional and is currently only available in research settings. Parents cannot opt out of motivational messages but can choose to receive messages through email or SMS. Some examples of motivational messages are presented in The HEAL program website was created by an in-house facility, the Center for Engineering Education and Outreach, at Tufts University between January and June 2015. The website has incorporated 4 active modules: Curriculum, SMART Plans, Logs, and Rewards . AdditioGrocery Store Scavenger Hunt, Create Your Own MyPlate, Eat the Rainbow, Grow Your Own Veggies, Sugar Detectives, Cook from Scratch, Drinks for Strong Bones and Teeth) and physical activity (such as Body Sketch-Hopscotch and Fun and Fast Circuit Course) for the whole family.The curriculum includes 12 weekly sessions outlining topics on targeted behaviors and specific barriers . Each seParents enrolled in the HEAL program are asked to complete the weekly self-guided curriculum; set up behavioral goals on parenting, nutrition, and physical activity using SMART plans; and complete weekly food and activity logs online (for at least 2 weekdays and 1 weekend per week) for 12 weeks. All curriculum sessions are accessible by the participants after they log in, although instructions are provided in the first session that they are expected to complete one session per week. The HEAL program has built-in functions that monitor how many minutes a HEAL user spends daily on each session to track usage. Based on the usage, the program sends automated motivational messages to parents after completion of goal-setting, logs, and curriculum session. Parents achieve Bronze, Silver, and Gold status after completing each of the 4 sessions as rewards, and children receive a digital certificate after completing family activities. At the end of each curriculum session, parents are encouraged to complete an online evaluation that asks them to rate statements about their knowledge of session-specific topics before and after each session on a 5-point Likert scale and answer open-ended questions on their perceptions of session strengths and weakness. As part of the study end assessment, parents are asked to complete a usability assessment once they have finished the program.Childhood cancer survivors are at substantially increased risk of developing cardiometabolic conditions at a young age. Although treatment exposure, alone or in combination, contributes to elevated CVD risk in childhood cancer survivors, the attributable fraction was less than 50%, ranging from 9.3% for hypertension, 15.5% for dyslipidemia, 41.7% for diabetes, and 42.1% for obesity [Many survivorship programs for childhood cancer lack a focus on nutrition, or when nutrition is introduced, the priority is to satisfy caloric needs and prevent weight loss. Although malnutrition due to cancer-related anorexia and cachexia still represents an important concern in cancer care , overconParenting styles and practices are important behavioral targets for weight management in childhood cancer survivors. For young survivors (aged 10 years or under) with limited autonomy and greater dependence on caregivers, family environment plays a highly influential role in facilitating a child’s eating and activity behaviors. For families with childhood cancer survivors, family environment can be even more important, because a close parent-child relationship is often expected in this context . QualitaAn important characteristic of childhood cancer survivors is that they are geographically dispersed. As a consequence, they have transportation difficulties coming to interventions delivered at a central location. Intensive time commitment to cancer-related care adds an additional barrier for families to participate in interventions scheduled at fixed times . On the In summary, lifestyle interventions are becoming a priority in cancer care to prevent excessive weight gain and early onset of CVD risk factors in childhood cancer survivors. These interventions must meet the targeted behavioral needs of the survivors; address specific barriers; capture a sensitive window for behavioral change; and be convenient, cost-effective, and scalable. Future research is needed to evaluate the feasibility of engaging pediatric ALL survivors and families in early weight management either within or outside cancer clinics and to assess participation, adherence, and retention rates. Such findings will provide an important foundation to inform the design and implementation of a fully-powered randomized controlled trial to evaluate the effect of early weight management on preventing unhealthy weight gain and CVD risk in young survivors of childhood ALL and to identify effective strategies to integrate weight management into cancer care and adapt the program to survivors with other cancer diagnoses.


In the 1940–50's Wilder Penfield and colleagues applied cortical electrical stimulation to patients undergoing epilepsy surgery to define what has become one of the landmarks on neuroscience: a map of the anatomical divisions of the body, divided in two cortical homunculi: sensory and motor  beyond motor control in both humans and animals. For instance, the role of M1 in visuomotor transformations, mental imagery, or mental rotation has been shown in studies dating more than 30 years ago  and how noninvasive brain stimulation can be used for reverting abnormal neuroplasticity associated with chronic pain . This focus of M1 neuromodulation on pain modulation is also the focus of original studies in different types of pain, such as chronic musculoskeletal and post stroke pain, pain related to chemotherapy, fibromyalgia, or neuropathic pain . Additionally, a framework addressing the contralateral inhibition of the impaired hemisphere following stroke and its potential relationship with central post stroke pain is proposed (Morishita and Inoue). A second common theme was the use of EEG to understand changes in M1, and correlate this neural signal with pain and emotional processing in stroke patients  and chronic pain secondary to rheumatoid arthritis . Furthermore, the use of neuroimaging was also the topic of one study assessing connectivity alterations in patients with rheumatoid arthritis and correlating increased pain perception with increased connectivity for the supplementary motor areas, mid-cingulate cortex, and the primary sensorimotor cortex . Finally roles of the motor cortex on other cognitive domains were also explored, namely M1 activation with real or mental imagery , kinematic changes associated with pain in patients with fibromyalgia , or changes in motor cortex activity following observation of emotionally laden pictures .This special topic comprises 15 articles from a diverse group of scientists that provide a robust contribution for the development to the field. We also want to acknowledge the invaluable help that all reviewers provided during this process—many of them leaders in their field—whose contribution improved significantly the manuscripts. The reviews in this special issue investigate the role of motor cortex when using stimulation techniques to M1 to investigate pain modulation  or top down (such as TMS or tDCS) interventions. Despite that, this special topic clearly emphasizes methods to probe and neuromodulate motor cortex functioning and its potential impact for comprehensive rehabilitation (such as pain). But those are only a few examples of how motor cortex is involved in pain processing and higher order cognitive processing.All authors listed, have made substantial, direct and intellectual contribution to the work, and approved it for publication.JL and SC are supported by the Portuguese Foundation for Science and Technology (FCT) and European Union (FSE-POPH) with individual awards FRH/BPD/86027/2012) and (IF/00091/2015). JL, SC are members of CIPSi, supported by the Portuguese Foundation for Science and Technology and the Portuguese Ministry of Science, Technology and Higher Education through national funds and co-financed by FEDER through COMPETE2020 under the PT2020 Partnership Agreement (POCI-01-0145-FEDER-007653); and also through the Portuguese Foundation for Science and Technology PTDC/MHC-PCN/3950/2014. FF is funded by the following NIH grants: R21HD079048, R01HD082302, 1R44NS080632-01, 1R44AT008637, HD069776.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 US Department of Veterans Affairs (VA) has developed various health information technology (HIT) resources to provide accessible veteran-centered health care. Currently, the VA is undergoing a major reorganization of VA HIT to develop a fully integrated system to meet consumer needs. Although extensive system documentation exists for various VA HIT systems, a more centralized and integrated perspective with clear documentation is needed in order to support effective analysis, strategy, planning, and use. Such a tool would enable a novel view of what is currently available and support identifying and effectively capturing the consumer’s vision for the future.The objective of this study was to develop the VA HIT Systems Matrix, a novel tool designed to describe the existing VA HIT system and identify consumers’ vision for the future of an integrated VA HIT system.This study utilized an expert panel and veteran informant focus groups with self-administered surveys. The study employed participatory research methods to define the current system and understand how stakeholders and veterans envision the future of VA HIT and interface design . Directed content analysis was used to analyze focus group data.The HIT Systems Matrix was developed with input from 47 veterans, an informal caregiver, and an expert panel to provide a descriptive inventory of existing and emerging VA HIT in four worksheets: (1) access and function, (2) benefits and barriers, (3) system preferences, and (4) tasks. Within each worksheet is a two-axis inventory. The VA’s existing and emerging HIT platforms , My HealtheVet features , and non-VA platforms  are organized by row. Columns are titled with thematic and functional domains . Cells for each sheet include descriptions and details that reflect factors relevant to domains and the topic of each worksheet.This study provides documentation of the current VA HIT system and efforts for consumers’ vision of an integrated system redesign. The HIT Systems Matrix provides a consumer preference blueprint to inform the current VA HIT system and the vision for future development to integrate electronic resources within VA and beyond with non-VA resources. The data presented in the HIT Systems Matrix are relevant for VA administrators and developers as well as other large health care organizations seeking to document and organize their consumer-facing HIT resources. The strategic plan of the US Department of Veterans Affairs (VA) aims to provide a modern, consistent health service experience to put veterans in control of how, when, and where they wish to be served ,2. The VAn aim of this VA-funded research was to develop a novel multiaxis Health Information Technology (HIT) Systems Matrix including currently available and desired future VA patient-facing platforms, their features, availability, and conditions for appropriate use. Although extensive system documentation exists for various VA HIT systems, a more centralized and integrated perspective with clear documentation is needed in order to support effective analysis, strategy, planning, and use. Such a tool would enable a novel view of what is currently available and support identifying and effectively capturing consumers’ vision for the future. The HIT Systems Matrix was developed with input from participants and expert panel members to represent relevant topics, such as access, function, preferences, barriers to use, and relevant user tasks. Topic-related data were organized using a matrix because, although it is treated as a single entity, diverse content can be documented and presented in a systematic way using rows and columns for ease of readability and matrix use.In this paper, we describe our protocol and product development process that leveraged a participatory approach to cultivating an inventory of the current HIT system used by the VA. Stakeholder groups and veteran informants were encouraged to include their vision for the future of VA’s tethered system of electronic resources.The HIT Systems Matrix is the first inclusive inventory of VA’s electronic health resources. It was developed in partnership with a panel of subject matter experts, operational and clinical stakeholders, and veteran/caregiver focus group participants. To develop the HIT Systems Matrix, expert panel members and veteran focus group participants provided initial descriptive information about VA and non-VA electronic health resources veterans may utilize for health care management. The protocol for this study has been previously published and can be referenced for a detailed description of the methods .In qualitative research such as this, sample size relies on the quality and richness of information obtained ,10. We pSnowball sampling was used to identify providers, key operational representatives, and subject matter experts who could serve as expert panel members. Initial invitations were sent via email to operational partners who were asked to assess gaps in representation and nominate other experts or stakeholders to participate. Over the course of 6 months, expert panel members were asked to participate in monthly HIT Systems Matrix development meetings, which culminated in the pairwise comparison activity . As indiResearchers used teleconference technology to collect initial descriptive data about VA electronic resources from expert panel members (n=34) to inform the development of the HIT Systems Matrix. Electronic mail was used to obtain individual panel member’s responses to the structured pairwise comparison activity. A total of 13 expert panel members completed the pairwise comparison activity. A total of 48 participants provided initial descriptive data about VA and non-VA HIT during the first round of focus groups and a total of 21 completed the pairwise comparison activity.Expert panel members and veterans were asked to provide information about each VA HIT system, including accessibility, function, and the perceived benefits and barriers related to using VA HIT. Participants were asked to supply additional descriptive information regarding their preferences for using VA HIT in general and complete specific health care management tasks. Additionally, veterans were also asked to provide information about the accessibility, function, and use of commonly used non-VA electronic health resources. Focus groups were conducted with veteran participants to complete the pairwise comparison process.The VA HIT Systems Matrix was developed iteratively. The first step was identifying the patient-facing HIT available to veterans, their features, and elements for prioritization. The research study team identified relevant VA HIT platforms , features , and elements for prioritization . This initial activity facilitated a focus on available HIT and their functions and features; the tool was revised throughout this process, particularly as data were collected from expert panel members and veterans in subsequent steps of the process. The second step focused on expanding content developed in the first step through an information gathering process with expert panel members. To complete this second step, we developed the initial model representing a detailed inventory of platforms, their features, characteristics, and contexts for use. The multiaxis HIT Systems Matrix included both existing and future (planned or desired) VA patient-facing platforms, their features, availability, and conditions for appropriate use. Due to the complexity of VA HIT and the elements of interest, the HIT Systems Matrix was developed using an Excel workbook with several worksheets representing relevant topics, such as access, function, preferences, barriers to use, and relevant user tasks.In the third step, we integrated data collected during veteran/caregiver focus groups to represent this user perspective. Focus group data was analyzed using content analysis. Directed content analysis allowed the team to focus on the core elements addressed in the focus group script items to identify patterns in descriptions of experience, behavior, and beliefs so that the phenomena could be understood within context . Focus gThe majority of participants were older, white, non-Hispanic/non-Latino males, with a mean age of 63.5 years (SD 8.4), ranging from 43 to 83 years of age (data not shown). Most participants had at least a high school education with an annual income of US $25,001 or more ; more than half  were married. Veterans were asked to list up to 10 of their chronic health conditions. Participants reported a mean of 6.5 (SD 1.89) conditions, ranging from 2 to 10 conditions (data not shown). Demographic data are presented in The expert panel included 34 representatives from 16 key VA operational offices and clinical disciplines including the VA’s Office of Mental Health; Office of Patient Centered Care and Cultural Transformation; Office of Rural Health; Office of Connected Health; Telehealth; My HealtheVet; VetLink Kiosks; Mobile Health; Human Factors; Pharmacy Informatics; Patient Education; and clinical disciplines such as primary care, specialty care, nursing, psychology, women’s health, and polytrauma.The VA HIT Systems Matrix is presented in Excel workbook spreadsheet format in Access and functionService availabilityAccessFunctionBenefits and barriersBenefits-expert panel membersBarriers-expert panel membersBenefits-veteran focus group participantsBarriers-veteran focus group participantsSystem preferencesAuthenticationDelegationReal-time synchronizationIntegration across platforms and with non-VA electronic resourcesSingle sign-onSecurityDesignTasksGeneral tasksCommunication with care teamLaboratory test resultsResearching medical informationTracking health vitalsAppointmentsManaging prescriptionsThis worksheet of the VA HIT Systems Matrix provides validated information from panel members about service availability, access requirements , and the function of each resource and feature. For example, eligibility and access requirements for the VA’s three My HealtheVet account types  were not well understood by contributors and were often cited as barriers to use. Account types offer three different levels of access to patients’ health records, so understanding requirements can significantly impact a patient’s experience. These findings suggested that veterans required more comprehensive information about VA HIT function in order to appropriately utilize these tools to meet their self-care management needs.This worksheet provides an overview of perceived VA HIT benefits and barriers from the panel and veterans’ perspectives. Benefits included 24-hour remote accessibility of appointment and prescription services, medical records, providers, and their ability to determine personal communication preferences. Panel members emphasized the efficiency and convenience of the resources and their benefit to patients. Barriers were related to accessibility, including limited access to requisite technologies or Internet connection and lack of available mobile technologies, lack of awareness of resources and how to use these resources, lack of accessibility to education, and navigation and system difficulties.Authentication refers to the one-time identity authorization process required to obtain a premium-use My HealtheVet account for full system access. Many participants recommended a secure, online authentication process as opposed to the existing in-person requirement, which was perceived as inconvenient. The VA subsequently added an online option for authentication. Veterans also noted preference for mobile options, such as a My HealtheVet mobile app. Delegation refers to regulatory requirements, policy issues, and veteran preferences about surrogate account access . Although unavailable at the time of the study, veterans felt that delegation represented a vital feature to the VA HIT system to better manage veterans’ care in partnership with informal caregivers and non-VA providers. Real-time synchronization and integration across platforms and with non-VA electronic resources details illustrate veterans’ preferences for an integrated, standardized, synchronized, and secure HIT system that integrates non-VA HIT across platforms such as kiosks and mobile apps. Single sign-on details addressed regulatory issues and veterans’ perceptions and concerns about the security and utility of federated credentialing, more commonly known as single sign-on. Security details provided by veteran participants indicate their clear concern for data privacy on VetLink Kiosks and mobile apps. Lastly, design details provided veteran input about the front-end user interface and experience when using VA HIT; most commonly, veteran participants stated a preference for simple “dashboard” designs that facilitated ease of use and continuity across resources and platforms.This worksheet addresses VA HIT system design preferences for authentication, delegation, synchronization, integration, sign-on, security, and interface design identified by panel and veterans’ groups. Veteran data clearly indicated that consumers used VA HIT to complete primary categories of tasks, including: (1) general tasks, (2) communication with care team, (3) laboratory test results/tests, (4) researching medical information, (5) tracking health vitals, (6) appointments, and (7) managing prescriptions. Data entries for these tasks provided veterans’ perspectives of the usefulness for utilizing each VA HIT resource and/or feature to complete the given task within different contexts. Due to the length and breadth of detail contained within the VA HIT Systems Matrix, the matrix document was structured to allow review and prioritization of content. The VA HIT Systems Matrix has search, filtering, and categorization options so content could be easily selected and compared .As previously stated, investments in education and marketing are necessary to promote veteran and provider access and sustained use of VA HIT. Thus, HIT Systems Matrix participants were asked to make consumer marketing and education recommendations for all VA HIT resources in order to address consumer confusion about resource access and function. Categories and recommendations are illustrated in DeliveryInvolve veteran service organizations  in educating veterans about VA HITTarget user groups who may require more assistance Provide peer-to-peer mentoring for sign-up instructions and updatesAllow an educator to access veteran’s computer to help set up My HealtheVet, create icons, and teach veterans about My HealtheVetHave providers’ market services in person; provide brochures at the time of appointments with providers that explain key elements of VA resourcesFormatProvide multiple types of education to fit all learning styles Use graphics and pictures to augment textProvide a VA welcome package or mail a digital video transmitter (DVD/YouTube) when veterans request their ID cards.CommunicationSend notifications about available technologies or changes to technologies Provide large print and display so veterans can read instructions easily in presentations My HealtheVet specificAdvertise tutorials/updates on VA sign-in pageIntegrate education on the My HealtheVet websiteProvide tutorials to learn more about My HealtheVetTroubleshootingEstablish a call desk to help veterans who are having trouble with aspects of VA HITInform veterans of the name and contact information for their My HealtheVet coordinatorIntegrated HIT systems improve health care delivery and help veterans become active participants in their care and self-care management; HIT is essential to adequately address veterans’ health care needs . DevelopThe goal of this participatory study was to inform the VA’s vision of an integrated HIT system from the shared perspective of veterans, providers, and key stakeholders . In alignment with the goals of the VA, the HIT Systems Matrix provides a descriptive blueprint for decision making and supports the ongoing development of a user-friendly HIT system that prioritizes increased access to personalized, proactive, and patient-driven virtual care. The utility of organizing and presenting information in the HIT Systems Matrix was threefold: (1) it allows users  to view and interpret direct stakeholder and veteran input despite its organizing structure because it was designed to allow sorting and manipulation of data; (2) it provides a living, evolving document that can be shared at any stage of development and that can be updated as HIT systems evolve; and (3) it allows users of the tool to easily compare and contrast the characteristics of different HIT technologies and platforms as well as understand the VA HIT system as a single entity.Although this study protocol and its HIT Systems Matrix product are useful in developing valuable knowledge to inform system improvements, this study has limitations. First, this study represented findings only relevant to the VA HIT systems and technologies; however, this study and its product may be useful for development and redesign of other tethered HIT systems in health care delivery. Second, current technological infrastructure capacity was not a primary focus and thus may have limited use of some findings although it should not limit the VA HIT vision of the future. Third, although our sample represented multiple stakeholder groups and was relatively small, it should be noted that participants were a representative, purposively sampled group and were comparable to sample sizes used in other qualitative mixed-methods studies . As suchFuture research should inform the ongoing development of VA’s vision for an integrated HIT system to include front-end patient user experiences and outcomes. Specifically, research should evaluate best practices for supporting consumers’ proactive and integrated use of VA HIT systems. Ongoing investigation in this area of research is also warranted to address identified barriers in the existing system and solutions to eliminating those barriers in the evolving VA HIT system. Issues for VA employees, including workload and workflow data, and organization-level research is needed to identify largescale infrastructural consequences and outcomes relevant to the supply and demand of the growing VA patient population. Finally, system preferences, such as single sign-on and delegation, merit further investigation to better understand the feasibility, acceptability, and usefulness of these features within the current and evolving VA HIT system across traditional  and emerging  technologies. Delegation in particular has become increasingly important because the VA places more emphasis on engaging with community care providers and informal caregivers. The provision of comprehensive and consistent veteran health care rests on the veteran’s ability to securely and easily delegate access to medical records and virtual health services.To our knowledge, this is one of the few published studies to aid in the development of an integrated system of HIT resources within a large health care system with nearly 4 million users . Future research should inform the ongoing development of VA’s vision for an integrated HIT system to include front-end patient user experiences and outcomes. Specifically, research should evaluate best practices for supporting consumers’ proactive and integrated use of VA HIT systems.Although this research lends itself to recommendations for future research, the authors’ aim in completing this work was to produce a useful resource to assist ongoing development, redesign, and research efforts. The VA is currently utilizing this tool to support multiple initiatives including the redesign of the patient portal, the design of an enterprise-wide delegation service, and has strategic communication plans to increase awareness and use of VA HIT. Beyond VA, other organizations can benefit from using a similar approach and may also find the matrix model useful as a template to enhance HIT analysis, strategy, planning, and use.


Now in beta, our aim is for this Android/iOS compatible mobile tool to simultaneously crowd-enroll the massive and growing community of families with autism to capture geographic, diagnostic, and resource usage information while automatically computing prevalence at granular geographical scales to yield a more complete and dynamic understanding of autism resource epidemiology.Although the number of autism diagnoses is on the rise, we have no evidence-based tracking of size and severity of gaps in access to autism-related resources, nor do we have methods to geographically triangulate the locations of the widest gaps in either the US or elsewhere across the globe. To combat these related issues of (1) mapping diagnosed cases of autism and (2) quantifying gaps in access to key intervention services, we have constructed a crowd-based mobile platform called “GapMap” ( Across the globe, families affected by autism must navigate substantial gaps in availability of health care resources. The incidence of autism has been on the rise in the USA and across the globe, but the rate and exact prevalence of autism remain unclear. Estimates from the Centers for Disease Control (CDC) represent extrapolations from a small collection of states, and by the time of publication, they can be up to 2 years out of date. Today’s alarming estimate of 1 in 68 children is based on data from 2014 [As the number of autism diagnoses has increased, so too has the number of children with a high risk for autism that remain undiagnosed . This trLittle attention has been paid to creating curated, easily Web-searchable, and comprehensive lists of autism services. The few exceptions include Autism Speaks  and AutiResource gaps (regions in which there exist limited diagnostic or treatment resources with respect to the demand) require comprehensive knowledge of both autism epidemiology and the geographic distribution of autism resources. Finding and understanding these resource gaps can drive novel innovation of products that can mobilize to the home and/or create shifts in resource usage to direct jobs and care towards particularly fillable gaps in care management for individuals with autism. This can be done through collecting robust hard data, allocating resources more efficiently, and providing information to emerging organizations and businesses to let them know where their services are needed most.While autism epidemiology is a common research area  and RzheUnderstanding the geographic distribution of autism resources is as difficult as understanding resource gaps. Although many ASD resource directories exist, most are for very small regions (at the city or state level) and can have data integrity drawbacks, including a lack of updated information, incomplete information, and missing resources. More importantly, very few ASD resource directories include critical information pertaining to diagnostic capability. The National Autistic Society United Kingdom’s Autism Services Directory  is an exDespite the difficulty, it is still worth finding closer approximations of the geographic distribution of autism and autism resources. Analyses conducted with 47,622 individuals with autism, based on information gathered from online public profiles and social media accounts, and 840 developmental medical centers in the USA, collected through Autism Speaks  and Autihttp://gapmap.stanford.edu), to obtain more accurate and widespread estimates of geographic variations in autism prevalence rates and resource availability. GapMap is a mobile-first website or an application that renders well and is fully usable from a mobile or tablet device but can also be accessed through a traditional computer. Minorities, households with an income of less than $50,000, and the non-college educated are more likely to use mobile Internet as their primary or only device for Internet access [To complement the resource lists from Autism Speaks and Autism Source, we have devised a tool, GapMap  , 14. ThiNeither the prevalence data nor the resource banks are complete, but a simple form lets individuals with autism (or caregivers of a child with autism) submit data. These data include gender, date of birth, location (city and state), specific diagnosis/co-morbid conditions, contact information, and local services that have been used. IP addresses, date and time of submission, and similarity of data submitted will be used to detect duplicate or flag anomalies as potentially falsified data. Participants also provide answers to a machine learning behavioral classification system, which has been shown to match clinical diagnostic outcomes with high frequency –29. CrowLocal services include medical specialists, therapists, support resources, and “autism-friendly” generic services. After submission, locational data will be anonymously incorporated into the prevalence map; all other data will be securely managed and used to better understand autism resource deficits. In the future, site visitors will also be able to easily add to or edit the autism resource bank and fill in ASD-specific information such as diagnostic capability, target age, and accommodated disorders/disabilities. While resource directories are often difficult and costly to maintain, as new services open and others shut down, crowdsourcing offers a lower cost solution: leverage the collective knowledge of individuals providing, using, and seeking resources. In particular, parents of young children are more likely to search for and share information online , and resData are encrypted and stored on secure MySQL databases behind a firewall. GapMap is written in React.js and runs on Amazon Web Services Simple Storage Serve (AWS S3). The backend server runs on AWS application program interface (API) Gateway and AWS Lambda. AWS API Gateway executes specific JavaScript packages, novel code that interacts with our SQL database, on AWS Lambda. The MySQL relational database is hosted on Amazon Relational Database Service (RDS) and consists of two main tables. Table 1 holds the resource data, including name/type of resource, geographic coordinates, address, and contact information. Table 2 holds participant data to include specific diagnosis, consent form, geographic location (zip code), and other personally identifiable information. See Fig. If successful, GapMap could help the families of 3.5 million individuals in the USA  quickly There is potential for bias in reporting and data capture that could skew the data incorporated into GapMap over time. To safeguard against biased reporting of autism diagnoses, we have incorporated a set of behavioral questions validated for autism detection by a series of machine learning experiments , 28. We Despite these limitations, utilizing crowdsourced data for the prevalence of diagnosed cases of autism and autism-related resources can impact positively on the quality of and access to robust information, through the involvement of an active and increasingly large population –39. GapM


In 2005, the Regional Committee for the World Health Organization (WHO) Western Pacific Region (WPR)MCV1 and MCV2 coverage data are reported annually to WHO and the United Nations Children’s Fund (UNICEF) from 36 of the 37 WPR countries and areas.https://stacks.cdc.gov/view/cdc/53519).Case-based measles and rubella surveillance data are reported monthly to WHO from all WPR countries and areas; 21 countries and areas of the Pacific Islands report data as one epidemiologic block.WPR experienced a resurgence of measles during 2013–2016 , after aAfter the request of the Western Pacific Regional Committee . Second, large-scale outbreaks occurred after importation of measles into countries with endemic, low-incidence measles. Third, multiple measles importations into countries or areas that had achieved elimination occurred, particularly in Mongolia, where a large outbreak persisted for >12 months and endemic measles virus transmission was reestablished.Measles incidence in WPR declined to a historic low of 5.2 in 2017 because of achievement of control of the outbreaks in Vietnam (2013–2014) and Mongolia (2015–2016), burnout of the outbreak in the Philippines (2013–2014), and China’s accelerated control of measles after the 2010–2011 outbreak. However, the resurgence during 2013–2016 revealed ongoing and emerging challenges that need to be addressed. These challenges include changing measles epidemiology, with increased measles incidence occurring among adolescents, young adults, and infants too young to be vaccinated as well as heterogeneity of measles epidemiology among subnational areas and specific groups at risk within countries with large populations. In addition, the resurgence revealed systems weaknesses: immunization programs were unable to achieve and maintain high population immunity through routine immunization service delivery, and some national laboratories had insufficient capacity to conduct timely serologic testing during outbreaks. The challenges identified also included inadequately developed and implemented policies and processes for preventing measles resurgence and morbidity after virus introduction to the population, including delayed outbreak investigation, insufficient outbreak response, and nosocomial measles virus transmission. Finally, the resurgence revealed a need for greater involvement of local governments, private sectors, societies, and communities.To address these challenges and to accelerate measles elimination efforts in WPR, the WHO Regional Office for the Western Pacific prepared a new strategy and plan of action for measles and rubella elimination in the Western Pacific that was endorsed by the 68th meeting of the WHO Regional Committee for the Western Pacific in October 2017  have made substantial progress toward measles elimination.During 2013–2016, a resurgence of measles occurred in WPR, with large-scale outbreaks in Mongolia, the Philippines, and Vietnam, and increased endemic transmission in China; in 2014, annual incidence increased to 68.9 cases per million. However, with control of the outbreaks, in 2017, incidence decreased to a new historic low (5.2 per million).Achieving high reported vaccination coverage is not sufficient for achieving regional measles elimination. Efforts by WPR countries are needed to establish high population immunity, build strong immunization systems, maintain high-quality surveillance, and improve outbreak preparedness and response.


As public health agencies struggle to track and contain emerging arbovirus threats, timely and efficient surveillance is more critical than ever. Using historical dengue data from Puerto Rico, we developed methods for streamlining and designing novel arbovirus surveillance systems with or without historical disease data. Flaviviridae and Togaviridae cause substantial illness and death worldwide  resulting from a linear regression of the estimated on the actual time series. In each repetition, we used a different combination of training data and testing data, and average all the scores across repetitions (denoted as Ȓ2). That is, we chose the set of providers that achieved the highest average out-of-sample performance , island-wide cases for each of the 4 dengue virus serotypes (Serotype), health region-specific cases for all 8 health service regions , and all objectives combined (Multi-objective). We assessed 3 alternative systems: population coverage (Population), patient volume (Volume), and patient geographic diversity (Diversity). The Multi-objective system reached 99% of maximum accuracy with just 22 providers  and public health goals  could be integrated into the systems. Such data were not available for this study. For newly emerging arboviruses, when historical data are not available, systems optimized for similar pathogens may provide reasonable coverage. Nonetheless, emergence dynamics may have more sporadic and explosive characteristics that may not be captured by a system designed to track spatiotemporal patterns of an endemic disease.Although surveillance goals and resources may be highly specific to the disease threat and region of concern, the proposed optimization method can be applied broadly to enhance the detection of infectious disease threats, as we have shown now for both dengue and influenza (Public health authorities seek situational awareness at multiple geopolitical scales as well as early warning of anomalous events across a wide spectrum of biologic threats beyond arboviruses. The method we present can also be used to redesign existing surveillance systems by manually including or excluding providers during optimization. Additionally, the method is well suited to integrating diverse data streams, such as climatic, mosquito vector, pharmacy, or digital data (In an era of “right-sizing,” quantitative development and evaluation are critical to the design, redesign, justification, and benchmarking of surveillance efforts. Given limited public health budgets on all scales, methods such as the one we present are critical to the future reliability and sustainability of infectious disease surveillance.Discussion of the methods and algorithm for provider selection with the goal of surveillance system optimization.