Correlations between Trunk Control and Balance in Children with Bilateral Spastic Cerebral Palsy

Impairments of postural responses are a salient feature of children with cerebral palsy (CP). While the systems approach describes balance in seven components, the relationship between trunk control and balance in children with CP has not been previously examined with all seven of these components. In this study, we aimed to identify correlations between trunk control and all seven systems approach balance components in children with bilateral spastic CP. Our participants were 30 children (M age = 11.83, SD = 2.32 years) with CP having a Gross Motor Function Classification System level ranging from I to III. We assessed trunk control with the Trunk Control Measurement Scale, including static and dynamic balance (selective voluntary control and reaching). Balance in standing was assessed using Kids-Mini-BESTest involving four domains: anticipatory, reactive, sensory orientation and stability in gait. We used Spearman's rank correlations to correlate trunk control and balance, and we obtained a moderate correlation between the trunk control measurement scale and the Kids-Mini-BESTest in children with both bilateral spastic CP (rs = .618, p < .001) and spastic diplegic CP (rs = .52, p = .02). Analysis of the correlations between separate domains of the Kids-Mini-BESTest and the trunk control measurement scale subscales revealed moderate correlations between the static sitting balance subscale and all four domains of the Kids-Mini-BESTest. The dynamic selective motor control subscale of the trunk control measurement scale moderately correlated with the anticipatory domain of the Kids-Mini-BESTest. The dynamic reaching subscale also correlated moderately with anticipatory and stability in gait domains. This correlation was statistically significant in the 13 to 17-year-old age group and was strong among females, whereas the correlation was moderate in males. Trunk control was moderately associated with balance considering all the systems theory components of balance in children with bilateral spastic cerebral palsy.

Exploring improvisations in road safety in a low-income setting

Road collision types repeat themselves, especially in low- and middle-income countries (LMICs), where countermeasures are often improvised and implemented with little planning. At the Shahbag intersection in Dhaka, Bangladesh, speed bumps were quickly constructed at the exit of the intersection as an improvised road safety measure following the occurrence of a fatal collision, which eventually contributed to another collision between a truck and a car. The events influencing the improvisation decision, and that action's consequences, have been analysed using the Impromap methodology, a variation of the Accimap approach that focusses specifically on improvisation. The applicability of the Impromap as a systems-based approach to the road safety domain is assessed using the predictions described in Rasmussen's risk management framework, and corresponding countermeasures are proposed. The analysis shows that improvisation in the road safety domain is undesirable irrespective of the economic setting as it is likely to eventually contribute to secondary collisions.Practitioner summary: In this paper, the events influencing the improvisation decision following a road crash, and that action's consequences, have been analysed using the Impromap methodology. The applicability of Impromap as a systems-based approach in road safety domain is assessed using the Rasmussen's risk management framework-based predictions, and corresponding countermeasures are proposed.

Pest Status, Bio-Ecology, and Area-Wide Management of Mirids in East Asia

Mirids (Hemiptera: Heteroptera: Miridae) feed upon a wide variety of cultivated and wild plants and can be economically important crop pests. They have traditionally been perceived as innocuous herbivores in East Asia; however, population levels of various mirid species have dramatically increased over the past decades. High-profile pests such as Apolygus spp., Adelphocoris spp., and Lygus spp. are now widely distributed across the region, and their infestation pressure is associated with climate, agroecological conditions, and farming practices. This review outlines how an in-depth understanding of pest biology, a systems-level characterization of pest ecology, and a comprehensive evaluation of integrated pest management tactics have enabled sustainable management of mirids across crop boundaries and harvest cycles. This work underscores how more holistic, integrative research approaches can accelerate the implementation of area-wide management of generalist pests, effectively prevent pest population build-up and yield impact, and shrink the environmental footprint of agriculture. In addition to highlighting the merits of interdisciplinary systems approaches, we discuss prospects and challenges for the sustainable management of polyphagous mirid pests in landscape matrices.

A reflection on the co-design approach to the development of the Medway Can campaign; a whole systems approach to obesity prevention using COM-B

Obesity is one of the highest metabolic risk factors associated with morbidity and mortality in the UK, with two-thirds of adults in the UK classed as overweight or obese. Whole systems approaches can be effective in tackling this public health challenge through stakeholder and key partner engagement. This article describes the co-design process for a social marketing obesity prevention campaign taking a whole systems approach based on the COM-B model of behaviour change. Development of social marketing campaigns through Agencies is often hampered by rapid turnaround and short timescales; we highlight how drawing on existing knowledge and co-design with beneficiaries can support the design, delivery and implementation of a social marketing behaviour change campaign.

Investigating the Impact of Automation on the Health Care Workforce Through Autonomous Telemedicine in the Cataract Pathway: Protocol for a Multicenter Study

BACKGROUND

While digital health innovations are increasingly being adopted by health care organizations, implementation is often carried out without considering the impacts on frontline staff who will be using the technology and who will be affected by its introduction. The enthusiasm surrounding the use of artificial intelligence (AI)-enabled digital solutions in health care is tempered by uncertainty around how it will change the working lives and practices of health care professionals. Digital enablement can be viewed as facilitating enhanced effectiveness and efficiency by improving services and automating cognitive labor, yet the implementation of such AI technology comes with challenges related to changes in work practices brought by automation. This research explores staff experiences before and after care pathway automation with an autonomous clinical conversational assistant, Dora (Ufonia Ltd), that is able to automate routine clinical conversations.

OBJECTIVE

The primary objective is to examine the impact of AI-enabled automation on clinicians, allied health professionals, and administrators who provide or facilitate health care to patients in high-volume, low-complexity care pathways. In the process of transforming care pathways through automation of routine tasks, staff will increasingly "work at the top of their license." The impact of this fundamental change on the professional identity, well-being, and work practices of the individual is poorly understood at present.

METHODS

We will adopt a multiple case study approach, combining qualitative and quantitative data collection methods, over 2 distinct phases, namely phase A (preimplementation) and phase B (postimplementation).

RESULTS

The analysis is expected to reveal the interrelationship between Dora and those affected by its introduction. This will reveal how tasks and responsibilities have changed or shifted, current tensions and contradictions, ways of working, and challenges, benefits, and opportunities as perceived by those on the frontlines of the health care system. The findings will enable a better understanding of the resistance or susceptibility of different stakeholders within the health care workforce and encourage managerial awareness of differing needs, demands, and uncertainties.

CONCLUSIONS

The implementation of AI in the health care sector, as well as the body of research on this topic, remain in their infancy. The project's key contribution will be to understand the impact of AI-enabled automation on the health care workforce and their work practices.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/49374.

Integrating Clinical and Socio-Environmental Approaches in Managing Rheumatoid Arthritis With Social Determinants of Health: A Case Study of an Elderly Patient in Rural Japan

Rheumatoid arthritis (RA) poses significant management challenges, especially in elderly patients living in rural areas with limited access to health care. This case report illustrates an integrative approach to managing RA, emphasizing the interplay of clinical, social, and environmental factors. A 72-year-old woman in a rural Japanese setting presented with progressive, widespread joint pain, initially self-managed with over-the-counter medications. Her condition, complicated by socioeconomic constraints and limited access to health care, necessitated a comprehensive management strategy. Clinical examination revealed bilateral joint tenderness, swelling, and high titers of rheumatoid factor and anti-citrullinated protein antibodies, confirming RA. Treatment included methotrexate and prednisolone, complemented by lifestyle modifications. Interdisciplinary collaboration among healthcare professionals, including nutritionists and physiotherapists, facilitated her management. The patient's care was guided by the chronic care model and the ecological model, addressing her clinical needs and socio-environmental context. This holistic approach resulted in improved clinical outcomes and enhanced quality of life. This case highlights the importance of a patient-centered, multidisciplinary approach in managing RA in rural settings. Integrating clinical management with an understanding of social determinants and patient empowerment is crucial for effective treatment. The case underscores the need for adaptable healthcare strategies that are sensitive to the unique challenges faced by elderly patients in rural communities.

A systems approach to the safety and efficiency of prescribing at the primary-secondary care interface

The interface between primary and secondary care represents a highly complex and heterogeneous system that continues to pose risks to the safety and quality of care. Many issues relate to prescribing activities, and suboptimal information sharing between stakeholders can lead to avoidable harm events and system inefficiencies that increase workload. The framework of a systems approach is used to structure four key interface issues: medicines reconciliation, prescribing at secondary care outpatient appointments, shared records, and quality of communication. We outline opportunities for improved safety and efficiency, and identify key barriers that need to be addressed. Significant further development is required for the measures discussed. We recommend the use of a systems approach to methodologically support this process, particularly due to the inherent system-wide understanding of problems that it generates. We argue such understanding is essential to ensure that risks and workload are not shifted around a system, without overall gain.

Whole systems approach to diet and healthy weight: a longitudinal process evaluation in East Scotland

AIMS

Obesity contributes to morbidity and early mortality, affecting people of all ages and sociodemographic backgrounds. Despite attempts to address obesity, efforts to date have only had limited success. Adopting a whole systems approach (WSA) may potentially address obesity and emphasise complex inter-relating factors beyond individual choice. This study aimed to assess implementation of WSA to diet and healthy weight in two council areas of Scotland, longitudinally exploring enablers and barriers. One area followed a Leeds Beckett WSA model (LBM) of implementation, while the other used a hybrid model incorporating existing working systems.

METHODS

To assess the process of implementing a WSA, interviews and focus groups were conducted after initiation and 1 year later.

RESULTS

Main enablers included: belief in WSA effectiveness; positive relationships between key personnel; buy-in at community and national levels; funding availability; the working group responsible for coordinating the system development comprising individuals with diverse expertise; good communication; and existing governance structures. Barriers included: insufficient funding; high staff turnover; inadequate training in WSA methodology; engaging all relevant stakeholders and reverting to 'old ways' of non-WSA working. The LBM provided a framework for system setup and generating an action plan.

CONCLUSION

This study provides the first independent longitudinal process evaluation of WSAs that have incorporated Leeds Beckett methodology, and offers insights into how a WSA can be implemented to address diet and healthy weight.

Enhancing research culture through PhD training: a systems approach to identifying leverage points for policy formation

This article examines the role of PhD training programmes in identifying and implementing positive interventions in research culture in the biosciences. Using a data set consisting of transcripts from interviews and group discussions with 179 participants from 18 of the current 23 (78%) UK-based Wellcome-funded PhD programmes, we apply a systems theory methodology to the system of higher education and PhD training. Using system mapping as an investigative tool, this approach identifies points of leverage within the system where policy interventions might be best targeted to affect changes to research culture in the global higher education sector. The results of this investigation highlight the student-supervisor relationship as a nexus for these interventions and recommends the programme structure as a global policy for PhD training.

Comprehensive application of a systems approach to obesity prevention: a scoping review of empirical evidence

A systems approach to obesity prevention is increasingly urged. However, confusion exists on what a systems approach entails in practice, and the empirical evidence on this new approach is unclear. This scoping review aimed to identify and synthesise studies/programmes that have comprehensively applied a systems approach to obesity prevention in intervention development, delivery/implementation, and evaluation. By searching international databases and grey literature, only three studies (10 publications) met inclusion criteria, which might be explained partially by suboptimal reporting. No conclusion on the effectiveness of this approach can be drawn yet due to the limited evidence base. We identified common features shared by the included studies, such as measuring ongoing changes, in addition to endpoint outcomes, and supporting capacity building. Some facilitators and barriers to applying a comprehensive systems approach in practice were identified. More well-designed and reported studies are needed, especially from low- and middle-income countries.

Understanding the hospital discharge planning process for medical patients with dementia

Background: Poor hospital discharge processes can result in the readmission of patients and potentially increase the stress levels of carers. Therefore, this study sought to understand the factors related to the discharge planning process for patients with dementia.Methods: The researchers interviewed 32 carers of patients with dementia and 20 hospital staff who worked on medical wards in a United Kingdom (UK) hospital. The semi-structured interviews were analysed thematically using a systems theory (patient-carer-staff relationships, hospital equipment and policies).Results: The findings indicated that the following factors could either have a positive or negative impact on discharge planning: patient (e.g. cognitive capacity), carer (e.g. preconceived ideas about care homes), staff (e.g. communication skills), policy (e.g. procedures such as discharge meetings), equipment (e.g. type of service provider delivering the equipment) and the wider social context (e.g. availability of specialist dementia beds in care homes).Conclusion: It is important for hospital staff to adopt a systems perspective and to integrate the different elements of the hospital system when planning for patients' discharge.

The Utility of Predictive Modeling and a Systems Process Approach to Reduce Emergency Department Crowding: A Position Paper

Emergency department (ED) crowding and its main causes, exit block and boarding, continue to threaten the quality and safety of ED care. Most interventions to reduce crowding have not been comprehensive or system solutions, only focusing on part of the care procession and not directly affecting boarding reduction. This position paper proposes that the ED crowding problem can be optimally addressed by applying a systems approach using predictive modeling to identify patients at risk of being admitted to the hospital and uses that information to initiate the time-consuming bed management process earlier in the care continuum, shortening the time during which patients wait in the ED for an inpatient bed assignment, thus removing the exit block that causes boarding and subsequently reducing crowding.

Beyond the big city: using a systems approach to cultivate a cycling culture in small cities and towns in Ireland

Urban mobility and how people move in our towns and cities is garnering more attention, as solutions are sought to multiple challenges faced by residents; health and physical inactivity, climate change, air quality, urbanisation and accessibility. Traditional, siloed approaches limit impact and collaborative, systems approaches hold promise. However, systems approaches often remain theoretical and few practical applications of their added value have been demonstrated. This study illustrates how a systems approach can be used to underpin the development of a 9-step process to generate solutions for action on active mobility. The development of a systems map and a theory of change framework are key outputs of this 9-step process. The purpose of this paper is to describe how a systems map was developed in an Irish town utilising broad stakeholder engagement to map the variables that influence cycling in the town and to identify the leverage points for transformational interventions.

Anaesthesia and patient safety in the socio-technical operating theatre: a narrative review spanning a century

We review the development of technology in anaesthesia over the course of the past century, from the invention of the Boyle apparatus to the modern anaesthetic workstation with artificial intelligence assistance. We define the operating theatre as a socio-technical system, being necessarily comprised of human and technological parts, the ongoing development of which has led to a reduction in mortality during anaesthesia by an order of four magnitudes over a century. The remarkable technological advances in anaesthesia have been accompanied by important paradigm shifts in the approach to patient safety, and we describe the inter-relationship between technology and the human work environment in the development of such paradigm shifts, including the systems approach and organisational resilience. A better understanding of emerging technological advances and their effects on patient safety will allow anaesthesia to continue to be a leader in both patient safety and in the design of equipment and workspaces.

A narrative review of staff views about dementia care in hospital through the lens of a systems framework

Background

Significant numbers of people with dementia are admitted into acute settings. They are likely to face poor health outcomes during hospitalisation. There is the need to fully understand the care provided to people with dementia through novel methods such as a systems approach (i.e. human interactions, policy, environment and equipment).

Aim

The aim of this literature review is to explore hospital practitioners' views on dementia care and to analyse findings using a systems approach.

Methods

We conducted a narrative review of primary studies that examined dementia care in acute settings. We analysed a total of 33 papers using Thomas and Harden's thematic synthesis guidelines.

Results

Thirty-three papers met the inclusion criteria for the review. The findings were as follows: (1) staff-patient relationships (e.g. coping with difficult behaviour), (2) staff-family relationships (e.g. the benefits of involving families in patient care), (3) staff-staff relationships (e.g. building a robust multidisciplinary team), (4) staff-patient care decisions (e.g. decisions directly related to the patient), (5) the environment (e.g. difficulty in adjusting to the hospital environment), (6) policies (e.g. hospital bureaucratic processes) and (7) equipment (e.g. pain assessment tools).

Conclusion

The paper revealed multidimensional challenges in the provision of dementia care within hospitals. We conclude that training programmes, hospital policies and processes aimed at improving outcomes for patients with dementia should adopt a systems approach which focuses on the relational, environmental, procedural and instrumental aspects of the hospital system.

Characterization of Boxwood Shoot Bacterial Communities and Potential Impact from Fungicide Treatments

Phyllosphere bacterial communities play important roles in plant fitness and growth. The objective of this study was to characterize the epiphytic and endophytic bacterial communities of boxwood shoots and determine how they may respond to commonly used fungicides. In early summer and early fall, shoot samples were collected immediately before and 1, 7, and 14 days after three fungicides containing chlorothalonil and/or propiconazole were applied to the canopy. Total genomic DNA from shoot surface washings and surface-sterilized shoot tissues was used as the template for 16S rRNA metabarcoding, and the amplicons were sequenced on a Nanopore MinION sequencer to characterize the epiphytic and endophytic communities. The bacterial communities were phylogenetically more diverse on the boxwood shoot surface than in the internal tissue, although the two communities shared 12.7% of the total 1,649 identified genera. The most abundant epiphytes were Methylobacterium and Pantoea, while Stenotrophomonas and Brevundimonas were the dominant endophytes. Fungicide treatments had strong impacts on epiphytic bacterial community structure and composition. Analysis of compositions of microbiomes with bias correction (ANCOM-BC) and analysis of variance (ANOVA)-like differential expression (ALDEx2) together identified 312 and 1,362 epiphytes changed in abundance due to fungicide treatments in early summer and early fall, respectively, and over 50% of these epiphytes were negatively impacted by fungicide. The two chlorothalonil-based contact fungicides demonstrated more marked effects than the propiconazole-based systemic fungicide. These results are foundational for exploring and utilizing the full potential of the microbiome and fungicide applications and developing a systems approach to boxwood health and production. IMPORTANCE Agrochemicals are important tools for safeguarding plants from invasive pathogens, insects, mites, and weeds. How they may affect the plant microbiome, a critical component of crop health and production, was poorly understood. Here, we used boxwood, an iconic low-maintenance landscape plant, to characterize shoot epiphytic and endophytic bacterial communities and their responses to contact and systemic fungicides. This study expanded our understanding of the above-ground microbiome in ornamental plants and is foundational for utilizing the full benefits of the microbiome in concert with different fungicide chemistries to improve boxwood health. This study also sets an example for a more thorough evaluation of these and other agrochemicals for their effects on boxwood microbiomes during production and offers an expanded systems approach that could be used with other crops for enhanced integrated pest management.

Adapting to Climate Change: Leveraging Systems-Focused Multidisciplinary Research to Promote Resilience

Approximately 2000 official and potential Superfund sites are located within 25 miles of the East or Gulf coasts, many of which will be at risk of flooding as sea levels rise. More than 60 million people across the United States live within 3 miles of a Superfund site. Disentangling multifaceted environmental health problems compounded by climate change requires a multidisciplinary systems approach to inform better strategies to prevent or reduce exposures and protect human health. The purpose of this minireview is to present the National Institute of Environmental Health Sciences Superfund Research Program (SRP) as a useful model of how this systems approach can help overcome the challenges of climate change while providing flexibility to pivot to additional needs as they arise. It also highlights broad-ranging SRP-funded research and tools that can be used to promote health and resilience to climate change in diverse contexts.

Future of Bacterial Disease Management in Crop Production

Bacterial diseases are a constant threat to crop production globally. Current management strategies rely on an array of tactics, including improved cultural practices; application of bactericides, plant activators, and biocontrol agents; and use of resistant varieties when available. However, effective management remains a challenge, as the longevity of deployed tactics is threatened by constantly changing bacterial populations. Increased scrutiny of the impact of pesticides on human and environmental health underscores the need for alternative solutions that are durable, sustainable, accessible to farmers, and environmentally friendly. In this review, we discuss the strengths and shortcomings of existing practices and dissect recent advances that may shape the future of bacterial disease management. We conclude that disease resistance through genome modification may be the most effective arsenal against bacterial diseases. Nonetheless, more research is necessary for developing novel bacterial disease management tactics to meet the food demand of a growing global population.

Efficacy of Various Low Temperature and Exposure Time Combinations for Thaumatotibia leucotreta (Meyrick) (Lepidoptera: Tortricidae) Larvae

A systems approach was developed as an alternative to a standalone quarantine disinfestation treatment for Thaumatotibia leucotreta in citrus fruit exported from South Africa. The systems approach consists of three measures: pre and postharvest controls and measurements, postpacking inspection, and postharvest exposure to low temperatures. Different cold treatment conditions with a range of efficacy levels can be used for this last measure. A series of trials reported here evaluated the efficacy of seven temperatures ranging from 0 to 5°C for durations from 14 d to 26 d. Mortality of the most cold-tolerant larval stages of T. leucotreta was determined. Temperatures of 0, 1, 2, and 3°C for 16, 19, 20, and 24 d respectively, induced 100% mortality of the tested populations. Probit 9 level treatment efficacy was achieved at 0 and 1°C for 16 and 19 d respectively. Mortalities higher than 90% were obtained with temperatures of 4, 4.5, and 5°C, after exposure for the longer durations. We demonstrated a significant difference in cold-induced insecticidal efficacy between 1, 2, 3, and 4°C. There was no significant difference in insecticidal efficacy between 4 and 4.5°C, but both of these temperatures were more efficacious than 5°C. The results of this study are valuable to support the use of cold treatment conditions with lower risk of fruit chilling injury in an effective systems approach, where the cold treatment efficacy can be augmented with other components of the systems approach.

Applying the Value Transformation Framework in Federally Qualified Health Centers to Increase Clinical Measures Performance

INTRODUCTION

The transition in health care from a volume-based to value-based model of care, combined with pressures brought about by the COVID-19 pandemic, makes the need for efficiency and coordination of the health center system imperative. The Value Transformation Framework (VTF), developed with health centers in mind, provides an organizing framework to support transformation of infrastructure, care delivery, and people systems.

METHODS

NACHC applied the VTF within a cohort of health centers across the country to drive systems change and improve performance on measures of clinical care.

RESULTS

A comparison of health centers "participating" in application of the VTF relative to "nonparticipating" health centers nationally showed improvement during 3 years of program implementation. Significant differences ( p < .05) favoring health centers who participated were noted for screening of colorectal cancer ( p < .001), depression ( p < .001), hypertension ( p < .001), obesity ( p = .001), and cervical cancer ( p = .011). Performance for diabetes control also favored participating programs, although the difference did not quite reach significance ( p = .45).

CONCLUSIONS

Applying a systems approach, organized by the VTF, with evidence-based interventions and deployed in a learning community, can result in improved performance across multiple measures of clinical care.

Geographic remoteness and socioeconomic disadvantage reduce the supportiveness of food and physical activity environments in Australia

OBJECTIVE

An analysis of food and physical activity environments in relation to socioeconomic disadvantage was conducted in 25 communities across Queensland, Australia.

METHODS

Physical activity and food environments were assessed in 25 Queensland communities using The Systematic Pedestrian and Cycling Environmental Scan (SPACES) and the Nutrition Environment Measurement Survey (NEMS). Spearman's correlation tested the association between physical activity and food environments and degree of remoteness and socioeconomic disadvantage of each region.

RESULTS

A significant negative association was observed between the supermarket food environment and degree of remoteness and socioeconomic disadvantage. All regions have a moderately supportive environment for physical activity. Food availability and price varied in supermarkets with more remote communities having less supportive food environments.

CONCLUSIONS

Areas with a high degree of remoteness and socioeconomic disadvantage were more likely to experience disadvantages in the physical activity, supermarket, and restaurant food environments than metropolitan areas and socioeconomically disadvantaged areas.

IMPLICATIONS FOR PUBLIC HEALTH

Socioeconomic disadvantage and remoteness were associated with reduced supportiveness of the built environment hindering the ability of consumers to make healthy food and physical activity choices. Improving the food and physical activity environments in these areas may assist in reducing the health inequalities experienced by these communities.

From classical mendelian randomization to causal networks for systematic integration of multi-omics

The number of studies with information at multiple biological levels of granularity, such as genomics, proteomics, and metabolomics, is increasing each year, and a biomedical questaion is how to systematically integrate these data to discover new biological mechanisms that have the potential to elucidate the processes of health and disease. Causal frameworks, such as Mendelian randomization (MR), provide a foundation to begin integrating data for new biological discoveries. Despite the growing number of MR applications in a wide variety of biomedical studies, there are few approaches for the systematic analysis of omic data. The large number and diverse types of molecular components involved in complex diseases interact through complex networks, and classical MR approaches targeting individual components do not consider the underlying relationships. In contrast, causal network models established in the principles of MR offer significant improvements to the classical MR framework for understanding omic data. Integration of these mostly distinct branches of statistics is a recent development, and we here review the current progress. To set the stage for causal network models, we review some recent progress in the classical MR framework. We then explain how to transition from the classical MR framework to causal networks. We discuss the identification of causal networks and evaluate the underlying assumptions. We also introduce some tests for sensitivity analysis and stability assessment of causal networks. We then review practical details to perform real data analysis and identify causal networks and highlight some of the utility of causal networks. The utilities with validated novel findings reveal the full potential of causal networks as a systems approach that will become necessary to integrate large-scale omic data.

Prevention Adaptation of an Evidence-Based Treatment for Parents Involved With Child Welfare Who Use Substances

Background: Parental substance use, especially opioid misuse and/or methamphetamine use, is a key driver for recent increases in family involvement with child welfare and foster care placements in the United States. There is an urgent need for programs that prevent parental substance use disorders, yet few prevention programs exist that target parents' unique needs and strengths. Adapting evidence-based treatment approaches for prevention might be an efficient, effective way to address this gap. The current study informed the rigorous adaptation of an evidence-based treatment that supports families involved with child welfare due to substance use, Families Actively Improving Relationships (FAIR), to a prevention-oriented intervention: "PRE-FAIR." FAIR entails four treatment domains: substance use, parenting, mental health, and ancillary services (e.g., housing, medical care, and food). FAIR significantly improved parenting and reduced parental substance use in three rigorous treatment trials, but FAIR's effectiveness in preventing the initiation or escalation of opioid misuse and/or methamphetamine use is untested. To inform adaptation, particular attention was paid to operationalizing strategies underlying a key hypothesized mediator of successful parent outcomes-engagement. Methods: Graduated FAIR parents (n = 9) and FAIR administrators, clinical supervisors, and clinicians (n = 11) participated in semi-structured interviews. Content analysis was used to identify key variables driving FAIR engagement and parent outcomes. Causal loop diagramming, a qualitative systems science method, was employed to operationalize emergent themes, and describe how causal links between key variables interrelated dynamically over time. Results: Themes reinforced the value of FAIR's treatment domains for supporting parent's sobriety and parenting skills within a prevention orientation. Ancillary supports and strong relationships were particularly crucial for helping parents cope with stressors leading to substance use. Five engagement strategies were identified as essential to parent success: 24/7 clinician availability, in-person clinician advocacy, in-home delivery, strengths-based interactions, and urinalysis. Implications for PRE-FAIR engagement strategies and dosage were identified. Discussion: Traditional qualitative analyses and qualitative analyses based in systems science can inform rigorous adaptations of evidence-based treatment programs for prevention. Future research will explore additional required, fidelity-consistent prevention adaptations to FAIR, and the impact of PRE-FAIR on parental substance use and child welfare case outcomes.

How can communication to GPs at hospital discharge be improved? A systems approach

Background

Poor communication to GPs at hospital discharge threatens patient safety and continuity of care, with reliance on discharge summaries that are commonly written by the most junior doctors. Previous quality improvement efforts have largely focused on adherence to standardised templates, with limited success. A lack of understanding has been identified as a cause of the issue’s resistance to decades of improvement work.

Aim

To understand the system of communication to GPs at hospital discharge, with a view to identifying potential routes to improvement.

Design & setting

A qualitative exploration of the secondary-to-primary care communication system surrounding a large UK hospital.

Method

A systems approach, recently defined for the healthcare domain, was used to structure and thematically analyse interviews (n = 18) of clinical and administrative staff from both sides of the primary–secondary care interface, and a subsequent focus group.

Results

The largely one-way communication system structure and the low level of hospital stakeholder insight into recipient GP needs emerged as consistent hindrances to system performance. More open lines of communication and shared records might enable greater collaboration to share feedback and resolve informational deficits. Teaching sessions and assessments for medical students and junior doctors led by GPs could help to instil the importance of detail and nuance when using standardised communication templates.

Conclusion

Facilitating the sharing of performance insights between stakeholder groups emerged as the key theme of how communication might be improved. The empirical measures proposed have the potential to mitigate the safety risks of key barriers to performance such as patient complexity.

Challenges and Approaches to Crop Improvement Through C3-to-C4 Engineering

With a rapidly growing world population and dwindling natural resources, we are now facing the enormous challenge of increasing crop yields while simultaneously improving the efficiency of resource utilization. Introduction of C4 photosynthesis into C3 crops is widely accepted as a key strategy to meet this challenge because C4 plants are more efficient than C3 plants in photosynthesis and resource usage, particularly in hot climates, where the potential for productivity is high. Lending support to the feasibility of this C3-to-C4 engineering, evidence indicates that C4 photosynthesis has evolved from C3 photosynthesis in multiple lineages. Nevertheless, C3-to-C4 engineering is not an easy task, as several features essential to C4 photosynthesis must be introduced into C3 plants. One such feature is the spatial separation of the two phases of photosynthesis (CO₂ fixation and carbohydrate synthesis) into the mesophyll and bundle sheath cells, respectively. Another feature is the Kranz anatomy, characterized by a close association between the mesophyll and bundle sheath (BS) cells (1:1 ratio). These anatomical features, along with a C4-specific carbon fixation enzyme (PEPC), form a CO₂-concentration mechanism that ensures a high photosynthetic efficiency. Much effort has been taken in the past to introduce the C4 mechanism into C3 plants, but none of these attempts has met with success, which is in my opinion due to a lack of system-level understanding and manipulation of the C3 and C4 pathways. As a prerequisite for the C3-to-C4 engineering, I propose that not only the mechanisms that control the Kranz anatomy and cell-type-specific expression in C3 and C4 plants must be elucidated, but also a good understanding of the gene regulatory network underlying C3 and C4 photosynthesis must be achieved. In this review, I first describe the past and current efforts to increase photosynthetic efficiency in C3 plants and their limitations; I then discuss a systems approach to tackling down this challenge, some practical issues, and recent technical innovations that would help us to solve these problems.

Pediatric Intensive Care Unit (PICU) Patient Room Design: Identifying Safety Risks in Mirrored Rooms Through a Graphical Systems Analysis

OBJECTIVE

The objectives of this study are to graphically depict specific clinical challenges encountered in a mirrored pediatric intensive care unit patient room and to represent potential solutions to address these challenges using a systems approach.

BACKGROUND

The intensive care unit (ICU) patient room is a highly complex patient care environment where the design of the room must support patient care delivery safely and efficiently. There is a lack of research examining how ICU design elements interact with other system components to impact patient care.

METHODS

An observational case study method utilizing a systems approach was used to observe and graphically depict clinical challenges with mirrored room configurations and to identify potential solutions. Video recordings of the three clinical scenarios were analyzed in detail in conjunction with three rounds of interviews with a clinical expert.

RESULTS

Equipment or task characteristics that require orienting to a specific side of a patient create challenges in a mirrored room. In order to deliver care safely and efficiently in the mirrored room, adaptations would be required including changing boom, equipment and team member locations, purchasing new equipment, staff training, and inventory management. Some procedures such as extracorporeal membrane oxygenation would be difficult to conduct safely in the mirrored room, even with significant adaptations.

CONCLUSION

Solutions to the challenges presented in mirrored room configurations are multifaceted and require simultaneous and ongoing changes to multiple systems elements, while others can be addressed relatively easily, for example, purchasing new equipment.

A transactional approach to patient safety: understanding safe care as a collaborative accomplishment

Within the last two decades, it has been commonly agreed that patient safety and error management in healthcare organizations can best be attained by adopting a systems approach via re-engineering efforts and the introduction of industrial safety technologies and methodologies. This strategy has not delivered the expected result. Based on John Dewey's pragmatism, we propose another vocabulary for understanding, inquiring into and learning from safety situations in healthcare. Drawing especially on Dewey's understanding of transaction as the inseparability between human and environment, we develop an analytical approach to patient safety understood as a transactional accomplishment thoroughly dependent on the quality of situated and shared habits and collaborative practices in healthcare. We further illustrate methodologically how a transactional attitude can be situationally practised through video-reflexive ethnography, a method that allows for inquiry into mundane safety practices by letting interprofessional teams see, reflect upon and possibly modify their shared practices and safety habits.

The cost of safety: Balancing risk and liberty in psychiatric units

The systems approach is a widely accepted method for addressing healthcare adverse events. However, when adverse events are behavioral in nature, such as self-injury or aggression, a systems approach can restrict patient autonomy. We propose guidelines for balancing safety and autonomy considerations when developing systems for behavioral adverse events: interventions that do not limit patient liberty, or that therapeutically address the root causes of behavioral adverse events, should be fully utilized. Clinicians should collaborate with patients when designing systems that may restrict patient liberty. And clinicians should be supported in managing the stress that accrues from working in hazardous environments.

Biological Control of a Phytosanitary Pest (Thaumatotibia leucotreta): A Case Study

Thaumatotibia leucotreta, known as the false codling moth, is a pest of citrus and other crops in sub-Saharan Africa. As it is endemic to this region and as South Africa exports most of its citrus around the world, T. leucotreta has phytosanitary status for most markets. This means that there is zero tolerance for any infestation with live larvae in the market. Consequently, control measures prior to exporting must be exemplary. Certain markets require a standalone postharvest disinfestation treatment for T. leucotreta. However, the European Union accepts a systems approach, consisting of three measures and numerous components within these measures. Although effective preharvest control measures are important under all circumstances, they are most critical where a standalone postharvest disinfestation treatment is not applied, such as within a systems approach. Conventional wisdom may lead a belief that effective chemical control tools are imperative to achieve this end. However, we demonstrate that it is possible to effectively control T. leucotreta to a level acceptable for a phytosanitary market, using only biological control tools. This includes parasitoids, predators, microbial control, semiochemicals, and sterile insects. Simultaneously, on-farm and environmental safety is improved and compliance with the increasing stringency of chemical residue requirements imposed by markets is achieved.

Human factors and ergonomics systems approach to the COVID-19 healthcare crisis

A human factors and ergonomics (HFE) systems approach offers a model for adjusting work systems and care processes in response to a healthcare crisis such as COVID-19. Using the Systems Engineering Initiative for Patient Safety (SEIPS) model of work system and patient safety, we describe various work system barriers and facilitators experienced by healthcare workers during the COVID-19 crisis. We propose a set of five principles based on this HFE systems approach related to novel pandemic: (i) deferring to local expertise, (ii) facilitating adaptive behaviors, (iii) enhancing interactions between system elements and levels along the patient journey, (iv) re-purposing existing processes and (v) encouraging dynamic continuous learning.

Making the Case for Proactive Strategies to Alleviate Homelessness: A Systems Approach

Homelessness is a complex public health issue that affects some of the most vulnerable populations in the United States. This study takes a holistic approach to better understand and analyze the multiple factors and their interconnections that contribute to the complexity of this problem. A systems analysis was conducted by utilizing the system dynamics method, which allows analyzing and comparing trends and behavior of system outcomes for different "what if" scenarios, interventions, and policy implications. Three leverage points were identified in this study to increase the effectiveness and efficiency of the current strategies to address homelessness: (1) increasing the number of affordable permanent housing units, (2) increasing the utilization of transitional housing units or shelters by the individuals experiencing homelessness, and (3) providing preventative services to at-risk populations before the onset of homelessness. Our results demonstrate that the most effective strategy is an amalgam of the solutions identified by these three leverage points. In addition, a policy analysis was conducted to study and estimate the effectiveness of various potential scenarios. This research provides data-driven and model-based insights into how decision-makers can utilize a systems approach to analyze new policy implications and create effective solutions to homelessness.

Fighting microbial pathogens by integrating host ecosystem interactions and evolution

Successful therapies to combat microbial diseases and cancers require incorporating ecological and evolutionary principles. Drawing upon the fields of ecology and evolutionary biology, we present a systems-based approach in which host and disease-causing factors are considered as part of a complex network of interactions, analogous to studies of "classical" ecosystems. Centering this approach around empirical examples of disease treatment, we present evidence that successful therapies invariably engage multiple interactions with other components of the host ecosystem. Many of these factors interact nonlinearly to yield synergistic benefits and curative outcomes. We argue that these synergies and nonlinear feedbacks must be leveraged to improve the study of pathogenesis in situ and to develop more effective therapies. An eco-evolutionary systems perspective has surprising and important consequences, and we use it to articulate areas of high research priority for improving treatment strategies.

Children's Environmental Health: A Systems Approach for Anticipating Impacts from Chemicals

Increasing numbers of chemicals are on the market and present in consumer products. Emerging evidence on the relationship between environmental contributions and prevalent diseases suggests associations between early-life exposure to manufactured chemicals and a wide range of children’s health outcomes. Using current assessment methodologies, public health and chemical management decisionmakers face challenges in evaluating and anticipating the potential impacts of exposure to chemicals on children’s health in the broader context of their physical (built and natural) and social environments. Here, we consider a systems approach to address the complexity of children’s environmental health and the role of exposure to chemicals during early life, in the context of nonchemical stressors, on health outcomes. By advancing the tools for integrating this more complex information, the scope of considerations that support chemical management decisions can be extended to include holistic impacts on children’s health.

Short report: Understanding the process of multilevel suicide prevention research trials

This paper reviews process evaluations associated with multilevel suicide prevention research trials. Process evaluations can provide important information about how multilevel suicide prevention models are implemented, their mechanisms of impact, and the context and elements of implementation that mediate effectiveness. Out of 42 papers identified, only four met selection criteria for including a process evaluation. Of these four, there was large variation in the level of detail provided, and only two studies specifically focused on the process of implementing a multilevelsuicide prevention model. Future trials should include targeted process evaluation, which can benefit a range of knowledge users.

Qualitative Evaluation of the STOEMP Network in Ghent: An Intersectoral Approach to Make Healthy and Sustainable Food Available to All

The STOEMP network is, to our knowledge, one of the first initiatives to bring different sectors together in a municipality so as to increase accessibility to healthy and sustainable foods for all, with particular attention for the disadvantaged population. This qualitative study aimed to gain an in-depth insight into how the STOEMP network aims to reach its goal of making healthy, sustainable food available to everyone, through an intersectoral, collaborative process, exploring the facilitators and challenges of taking a systems-oriented approach to achieving this. Interviews were conducted among 15 stakeholders of the STOEMP network between March-July 2019 in Ghent (Belgium). Factors that facilitated the development and work of the network are reported, including having an external, neutral process manager, shared values, multisector engagement, enthusiasm, resources, and sense of ownership, as well as the barriers that were faced, such as time issues, uncertainty regarding continuation and funding, and discrepancy in visions. These issues reflect the strengths and challenges of taking a systems approach that aims to formulate solutions to widening access to healthy and sustainable foods. STOEMP would like to influence policy and thereby strengthen its impact, but needs further discussions to collectively formulate exact needs.

Assessment of the Systems Approach for the Phytosanitary Treatment of Wood Infested With Wood-Boring Insects

Addressing the risk from pests present in wood and wood products destined for international trade is an essential step towards minimizing the movement, introduction and establishment of invasive species. One method of managing the pest risk associated with wood commodities is the use of a systems approach that incorporates multiple independent measures applied along a production pathway. However, quantifying the reduction of risk can be difficult because the approach requires raw material infested with the pest of interest at a sufficient density to be able to quantify changes in pest abundance. We tested a systems approach for the production of sawn wood using green ash, Fraxinus pennsylvanica Marshall (Lamiales: Oleaceae), infested with emerald ash borer, Agrilus planipennis Fairmaire (Coleoptera: Buprestidae), by quantifying the change in pest density during the milling process and the precise effect of heat treatment on insects in situ. Greater than 90% of emerald ash borer were removed at the first step of the milling process (debarking) and >99% were removed before the production of green sawn wood. No insects survived kilning or heat treatment. All life stages of emerald ash borer were killed at 56°C and above. Heat, however, had no sublethal effect on emerald ash borer performance. These results show that the application of a systems approach to mitigate emerald ash borer in heat-treated, sawn wood is effective. Moreover, the model-system approach developed in this study can be a template for investigating the effect of systems approaches for other phloem-feeding insects.

An Improved Systems Approach as a Phytosanitary Measure for Thaumatotibia leucotreta (Lepidoptera: Tortricidae) in Export Citrus Fruit From South Africa

A systems approach was previously developed for mitigating phytosanitary risk of Thaumatotibia leucotreta (Meyrick) in citrus fruit exported from South Africa, as an alternative to a standalone cold disinfestation treatment. The present study first tested the original systems approach by applying it on a semicommercial scale in 10 Nova mandarin orchards. Fruit were inspected at points in the production, packing, and simulated shipping process, to assess performance of the systems approach. Additional data were obtained from 17 Valencia orange orchards and six packinghouses. In the second part of this study, the systems approach was accordingly revised and improved, consisting of three measures: 1) preharvest controls and measurements and postpicking sampling, inspection, and packinghouse procedures; 2) postpacking sampling and inspection; and 3) shipping conditions. The model quantifying the effectiveness of the systems approach was improved by correcting errors in the original version, updating parameter values and adding a component that provides for comparison with the risk mitigation provided by a standalone disinfestation treatment. Consequently, the maximum potential proportion of fruit that may be infested with live T. leucotreta after application of the improved systems approach is no greater than the proportion of fruit that may be infested after application of a Probit 9 efficacy postharvest disinfestation treatment to fruit with a 2% pretreatment infestation. The probability of a mating pair surviving is also determined. The model enables a priori determination of the required threshold levels for any of the three measures, based on quantification of the other two measures.

The Lean and Agile Multi-dimensional Process (LAMP) - a new framework for rapid and iterative evidence generation to support health-care technology design and development

Introduction: Health technology assessments (HTA) are tools for policymaking and resource allocation. Early HTAs are increasingly used in design and development of new technologies. Conducting early HTAs is challenging, due to a lack of evidence and significant uncertainties in the technology and the market. A multi-disciplinary approach is considered essential. However, an operational framework that can enable the integration of multi-dimensional evidence into commercialization remains lacking.Areas covered: We developed the Lean and Agile Multi-dimensional Process (LAMP), an early HTA framework, for embedding commercial decision-making in structured evidence generation activities, divided into phases. Diverse evidence in unmet needs, user acceptance, cost-effectiveness, and market competitiveness are being generated in increasing depth. This supports the emergence of design and value propositions that align technology capabilities and clinical and user needs.Expert opinion: We have been applying LAMP to working with medical device and diagnostic industry in the UK. The framework can be adapted to suit different technologies, decision needs, time scales, and resources. LAMP offers a practical solution to the multi-disciplinary approach. Methodologists drive the process by performing evidence generation and synthesis as and by enabling interactions between manufacturers, designers, clinicians, and other key stakeholders.

Nurses' perceptions of systems thinking and safe nursing care: A cross-sectional study

AIM

To assess nurses' perceptions of systems thinking, safe nursing care and the correlation between them.

BACKGROUND

Systems thinking and safe nursing care are the key elements of quality improvement approaches, such as accreditation and patient safety programmes. However, these two variables have not been well studied in different health care settings.

METHODS

In this cross-sectional study, 300 nurses were selected using the stratified random sampling method. The data were collected using a demographic data form, systems thinking scale and assessment of safe nursing care questionnaire.

RESULTS

The scores of nurses' perceptions of systems thinking (63.25 ± 9.20) and safe nursing care (4.13 ± 0.60) were above average. A positive correlation was found between systems thinking and safe nursing care (r = .66, p < .001), and its dimensions: nursing skills (r = .61, p < .001), psychological needs (r = .56, p < .001), physical needs (r = .51, p < .001) and teamwork (r = .56, p < .001).

CONCLUSION

Regarding the correlation between systems thinking and safe nursing care, nurses and other medical professionals, especially novices, are recommended to strengthen their systems thinking skills to improve the safe nursing care.

IMPLICATIONS FOR NURSING MANAGEMENT

Nurse managers should deal with organisational condition and factors affecting some poor aspects of systems thinking and safe nursing care. They must lead, support and allocate resources to the foundations of systems thinking to achieve safe nursing care.

Resilience of informal settlements to climate change in the mountainous areas of Konso, Ethiopia and QwaQwa, South Africa

Managing change is essential for human survival; thus, the importance of adapting to climate change has been increasingly recognised by researchers and governments alike. This is reflected in the growing literature on climate change and the imperative for action including building resilience in our socio-ecological systems. Despite the large body of research that now exists, few studies have considered the resilience of informal rural or peri-urban settlements in mountainous regions. This article considered the resilience of two rural settlements in mountainous areas, namely Konso, Ethiopia, and QwaQwa, South Africa, to the influences of climate change based on the assets available to them. The authors obtained the local communities' perception of their risks throsugh interviews with community leaders and a survey of 384 residents, divided equally between each settlement. Furthermore, the resilience of each community was assessed on the basis of their environmental, social, economic, human, institutional and physical capitals using a climate change resilience indicator. The findings showed that both communities faced major challenges because of climate change, particularly from drought and poverty. We found that both communities retained some forms of indigenous knowledge, but its greater application in Konso appeared to improve resilience to a greater extent than QwaQwa, where it played a lesser role and the community was more dependent on the government. However, indigenous knowledge alone is not sufficient to support these communities in the long term, given the growing aridity of the regions, and other approaches are also necessary, including government support, to enhance and grow their capitals.

Effectiveness of Hot-Water Immersion Against Brevipalpus yothersi (Acari: Tenuipalpidae) as a Postharvest Treatment for Lemons

Citrus leprosis is a destructive disease of citrus caused by several viruses (CiLVs) that are quarantine pests in the United States. Brevipalpus yothersi Baker (Acari: Tenuipalpidae) vectors the most virulent strain of CiLV. This mite is present in the United States and could facilitate the spread of the disease if CiLV reaches the country. Postharvest treatments could mitigate B. yothersi on imported commodities from areas where CiLV exists. The current study explores the effectiveness of hot-water immersion as a postharvest treatment against B. yothersi. Lemons were immersed in water at 21, 48, 53, or 63°C for 5, 10, and 15 min. Immersions at 53 and 63°C for all time schedules dislodged over 99% of adult mites. Lemon fruit quality and B. yothersi egg viability after hot-water immersion were also evaluated. Fruit quality significantly decreased in lemons treated at 63°C resulting in decay (grade 3, rejection), while at 53°C there was a quality reduction (grade 2, minimum acceptable market level) compared to lemons immersed at 21°C or nontreated controls (grade 1). None of the eggs hatched when the lemons were immersed in water at 63°C and an average of 1.5% hatched at 53°C for all time schedules. Immersion in water at 53°C for 5 min dislodged 99.71% and 57.14% of adult and immature mites, respectively, and resulted in 98.11% unhatched eggs without significant fruit quality reduction. Hot-water immersion could be a key component in a systems approach to control B. yothersi on imported citrus fruits from countries where citrus leprosis is present.

Applying systems approach for bridging education, research, and patient care in a health sciences university

Systems approach provides a logical and scientific basis for explaining the functioning of a system in a holistic manner. The health sciences university is a system with its three major operations – education, research, and patient care, which can be conceived as inputs, process, and output, respectively. The system is aided by a feedback loop to inform and correct the system. Systems thinking enable us to identify the deficiencies existing in each of the components so that appropriate remedial action can be taken. In this article, we have identified deficiencies in the health sciences system. Further, we have suggested a five-point formula to achieve connection among education, research, and patient care. We need to Form consortia and networks to create a mass movement, Uniform regulations to remove bottlenecks, Reform curricula to make them credit linked and competency based, Inform all through a faculty development initiative, and finally, Transform the system by setting examples and demonstrating success. The initiative taken by the Medical Council of India in introducing a competency-based curriculum for MBBS, and the revised accreditation manual introduced by the National Assessment and Accreditation Council can provide a lot of opportunities to explore the potentiality educational research to answer many questions that can help us in connecting research with education and patient care.

Driver distraction and inattention in fatal and injury crashes: Findings from in-depth road crash data

Objective: This study investigated the contribution of driver distraction and inattention within fatal and injury crashes using recent in-depth road crash investigation data. To assist in developing system-based solutions, this study also examined the wider context in which inattention-related crashes occurred and the characteristics of inattentive drivers. Methods: The sample included in-depth crash data from 186 fatal and injury crashes in South Australia investigated from 2014 to 2018. Crash case notes were reviewed to determine whether there was evidence that attentional failures contributed to the crash. Using an adapted taxonomy of inattention, 5 subtypes of driver inattention were defined: Misprioritized attention, neglected attention, cursory attention, diverted attention (distraction), and unspecified inattention. The characteristics of inattention crashes were also compared with those for non-inattention-related crashes. Results: Of the 160 crashes for which there was sufficient information to determine whether inattention was a factor, 31.3% showed evidence of driver inattention contributing to the crash. The most common subtypes of inattention were distraction (13.8% of all crashes) and driver misprioritized attention (8.1%). The distraction-related crashes included a variety of different distractions, the majority of which were not technology based (e.g., passenger interaction, searching for/adjusting objects, emotional stress, other road users), with those located in-vehicle the most prevalent. Distraction from mobile phone use was identified in 2.5% of all crashes. The majority of distractions were cognitive (64%) and voluntary (77%) in nature. Inattention crashes were most likely to involve right turn/angle or rear-end crash types and occur at intersections, in metropolitan areas, and in lower speed zones. Conclusions: The findings established that almost a third of fatal and injury crashes involved driver inattention and distraction and many of these could have been prevented. System-wide solutions that could mitigate or prevent distraction crashes include intervening vehicle safety technologies, infrastructure solutions to promote a forgiving road environment, blocking capabilities within technologies to prevent communications while driving, and interventions communicating the risks associated with inattention. Of significance, this study also demonstrated the importance of in-depth data for understanding the contribution of distraction and inattention errors in crash causation.

(Re)Introducing Vygotsky's Thought: From Historical Overview to Contemporary Psychology

Theories formulated by Russian psychologist and educator Lev Vygotsky currently range from being applied and celebrated across multiple contexts to be considered outdated. In this paper, we maintain that such inconsistency in application stems from the overreliance on translated or reformulated Vygotskian theories, the attempts to understand these ideas in isolation from the scientific historical context of their development, and the impact of Vygotsky's personal life circumstances on the development of his scholarship. It is known that Vygotsky's untimely death prevented him from elaborating on his theoretical views and expanding his early empirical work. We suggest that Vygotsky's scholarship could be better understood in light of the core principles that transcend all aspects of his work. In this paper, we elaborate on two such core principles: theories of language development and their relation to the integrated systemic approach to psychological development. We argue that although linguistic and historical boundaries have shaped the common perception of Vygotskian theories in anglophone research in a specific way, there is a potential for a renewed application of these theories to modern psychology that might be especially relevant in light of the increasingly interdisciplinary character of the modern science. To support our argument, we provide a brief overview and examples of potential connections between Vygotsky's scholarship with contemporary landscape in psychological science. The paper presents a brief introduction to the topic of Vygotskian work and its application to modern psychology, rather than an addition to the field of Vygotskian scholarship. It is geared toward non-Vygotskian scholars and invites researchers working in interdisciplinary areas of psychology.

Artificial Intelligence Based Approaches to Identify Molecular Determinants of Exceptional Health and Life Span-An Interdisciplinary Workshop at the National Institute on Aging

Artificial intelligence (AI) has emerged as a powerful approach for integrated analysis of the rapidly growing volume of multi-omics data, including many research and clinical tasks such as prediction of disease risk and identification of potential therapeutic targets. However, the potential for AI to facilitate the identification of factors contributing to human exceptional health and life span and their translation into novel interventions for enhancing health and life span has not yet been realized. As researchers on aging acquire large scale data both in human cohorts and model organisms, emerging opportunities exist for the application of AI approaches to untangle the complex physiologic process(es) that modulate health and life span. It is expected that efficient and novel data mining tools that could unravel molecular mechanisms and causal pathways associated with exceptional health and life span could accelerate the discovery of novel therapeutics for healthy aging. Keeping this in mind, the National Institute on Aging (NIA) convened an interdisciplinary workshop titled “Contributions of Artificial Intelligence to Research on Determinants and Modulation of Health Span and Life Span” in August 2018. The workshop involved experts in the fields of aging, comparative biology, cardiology, cancer, and computational science/AI who brainstormed ideas on how AI can be leveraged for the analyses of large-scale data sets from human epidemiological studies and animal/model organisms to close the current knowledge gaps in processes that drive exceptional life and health span. This report summarizes the discussions and recommendations from the workshop on future application of AI approaches to advance our understanding of human health and life span.

'At the grass roots level it's about sitting down and talking': exploring quality improvement through case studies with high-improving Aboriginal and Torres Strait Islander primary healthcare services

OBJECTIVES

Improving the quality of primary care is an important strategy to improve health outcomes. However, responses to continuous quality improvement (CQI) initiatives are variable, likely due in part to a mismatch between interventions and context. This project aimed to understand the successful implementation of CQI initiatives in Aboriginal and Torres Strait Islander health services in Australia through exploring the strategies used by 'high-improving' Indigenous primary healthcare (PHC) services.

DESIGN, SETTINGS AND PARTICIPANTS

This strengths-based participatory observational study used a multiple case study method with six Indigenous PHC services in northern Australia that had improved their performance in CQI audits. Interviews with healthcare providers, service users and managers (n=134), documentary review and non-participant observation were used to explore implementation of CQI and the enablers of quality improvement in these contexts.

RESULTS

Services approached the implementation of CQI differently according to their contexts. Common themes previously reported included CQI systems, teamwork, collaboration, a stable workforce and community engagement. Novel themes included embeddedness in the local historical and cultural contexts, two-way learning about CQI and the community 'driving' health improvement. These novel themes were implicit in the descriptions of stakeholders about why the services were improving. Embeddedness in the local historical and cultural context resulted in 'two-way' learning between communities and health system personnel.

CONCLUSIONS

Practical interventions to strengthen responses to CQI in Indigenous PHC services require recruitment and support of an appropriate and well prepared workforce, training in leadership and joint decision-making, regional CQI collaboratives and workable mechanisms for genuine community engagement. A 'toolkit' of strategies for service support might address each of these components, although strategies need to be implemented through a two-way learning process and adapted to the historical and cultural community context. Such approaches have the potential to assist health service personnel strengthen the PHC provided to Indigenous communities.