Distributional impact of infectious disease interventions in the Ethiopian Essential Health Service Package: a modelling study

OBJECTIVES

Reducing inequalities in health and financial risk are key goals on the path toward universal health coverage, particularly in low-income and middle-income countries. The design of the health benefit package creates an opportunity to select interventions through established criteria. The aim of this study is to examine the health equity and financial protection impact of selected interventions, along with their costs, at the national level in Ethiopia.

DESIGN

Distributional cost-effectiveness analysis.

POPULATION

The eligible population for all selected interventions is assumed to be 10 million.

DATA SOURCES

Data on disease prevalence and population size were gathered from the Global Burden of Disease database, and average health benefits and program costs are sourced from the Ethiopian Essential Health Service Package (EHSP) database, national surveys and other publicly available sources.

INTERVENTION

A total of 30 interventions were selected from the latest EHSP revision and analysed over a 1-year period.

OUTCOME MEASURES

Health benefits, social welfare indices and financial protection metrics across income quintiles were reported.

RESULTS

We found 23 interventions that improve population health and reduce health inequality and four interventions reduce both population health and health inequality. Additionally, three interventions improve population health while increasing health inequality. Overall, the EHSP interventions provide a 0.021 improvement in health-adjusted life expectancy (HALE) per person, with a positive distributional equity impact: 0.029 (26.9%) HALE gained in the poorest and 0.015 (14.0%) in the richest quintile. Similarly, a total of 1 79 475 cases of catastrophic health expenditure were averted, including 82 100 (46.0%) cases in the poorest and 17 900 (10.0%) in the richest quintile.

CONCLUSION

Increasing access to the EHSP improves health equity and financial protection. Improved access to selected EHSP interventions also has the potential to provide greater benefits to the poorest and thereby improve social welfare.

Dissociable effects of positive feedback on the capture and inhibition of impulsive behavior in adolescents with ADHD versus typically developing adolescents

The present study investigated how enhancing motivation by delivering positive feedback (a smiley) after a successful trial could affect interference control in adolescents with Attention Deficit Hyperactivity Disorder (ADHD) and in their typically developing (TD) peers. By using a Simon task within the theoretical framework of the "activation-suppression" model, we were able to separately investigate the expression and the inhibition of impulsive motor behavior. The experiment included 19 adolescents with ADHD and 20 TD adolescents in order to explore whether data found in adolescents with ADHD were similar to those found in TD adolescents. Participants performed the Simon task in two conditions: a condition with feedback delivered after each successful trial and a condition with no feedback. The main findings were that increasing motivation by delivering positive feedback increased impulsive response in both groups of adolescents. It also improved the efficiency of impulsive motor action inhibition in adolescents with ADHD but deteriorated it in TD adolescents. We suggest that 1/increased motivation could lead adolescents to favor fast responses even if incorrect, and 2/the differential effect of feedback on the selective suppression of impulsive motor action in both groups could be due to different baseline DA levels.

Developmental changes in impulse control: Trial-by-trial EMG dissociates the evolution of impulse strength from its subsequent suppression

Goal-oriented behavior can be disrupted by irrelevant information that automatically activates incorrect responses. While behavioral errors reveal response capture in such situations, they are only the tip of the iceberg. Additional subliminal activations of the incorrect responses (partial errors) can be revealed on correctly responded trials thanks to electromyography (EMG). In the current study, for the first time, EMG recorded in children was combined with distributional analyses. This allowed to investigate the properties of incorrect response activations and to highlight developmental changes in impulse control. A sample of 114 children aged 6-14 years was studied. Children performed a Simon task in which the irrelevant stimulus-position automatically activates a response that might be compatible or incompatible with the correct one. On incompatible trials, the automatic response activation must be overcome by controlled response selection. As previously observed in adults, our approach revealed the presence of an automatic EMG activation of the incorrect response elicited by the irrelevant stimulus dimension. Further, it revealed another independent source at the origin of incorrect response activations: the tendency to guess for response alternation. Both sources increased the frequency of early incorrect EMG activations, indicating impulsive responding. In addition, the influence of both sources decreased with increasing age. Thus, development is marked by improved ability to manage distractibility on the one hand and decreased tendency to rely on a guessing strategy on the other.

Cognitive effects of acute aerobic exercise: Exploring the influence of exercise duration, exhaustion, task complexity and expectancies in endurance-trained individuals

The cognitive effects of acute aerobic exercise were investigated in endurance-trained individuals. On two occasions, 21 cyclists; 11 male (VO_2max: 57 ± 9 mL·kg^-1·min^-1) and 10 female (VO_2max: 51 ± 9 mL·kg^-1·min^-1), completed 45 min of fixed, moderate-intensity (discontinuous) cycling followed by an incremental ride to exhaustion. Cognitive function was assessed at Baseline, after 15 and 45 min of exercise (15EX and 45EX) and at Exhaustion using a 4-Choice Reaction Time (CRT) test and the Stroop test (Incongruent and Congruent Reaction Time [RT]). A sham capsule was administered on one occasion to determine whether the cognitive response to exercise was robust to the influence of a placebo. CRT, Congruent RT and Incongruent RT decreased (improved) at 15EX, 45EX and Exhaustion compared to Baseline (p's<0.005). While CRT and Congruent RT were faster at 45EX than 15EX (p's<0.020), Incongruent RT was not (p= 1.000). The sham treatment did not affect cognition. When performed at a moderate-intensity, longer duration exercise (up to 45 min) may improve cognition to a greater extent than shorter duration exercise; however, the magnitude of improvement appears to decrease with increasing task complexity. HI/EE performed following a sustained bout of dehydrating activity may not impair cognition.

Masked Morphological Priming in German-Speaking Adults and Children: Evidence from Response Time Distributions

In this study, we looked at masked morphological priming effects in German children and adults beyond mean response times by taking into account response time distributions. We conducted an experiment comparing suffixed word primes (kleidchen-KLEID), suffixed nonword primes (kleidtum-KLEID), nonsuffixed nonword primes (kleidekt-KLEID), and unrelated controls (träumerei-KLEID). The pattern of priming in adults showed facilitation from suffixed words, suffixed nonwords, and nonsuffixed nonwords relative to unrelated controls, and from both suffixed conditions relative to nonsuffixed nonwords, thus providing evidence for morpho-orthographic and embedded stem priming. Children also showed facilitation from real suffixed words, suffixed nonwords, and nonsuffixed nonwords compared to unrelated words, but no difference between the suffixed and nonsuffixed conditions, thus suggesting that German elementary school children do not make use of morpho-orthographic segmentation. Interestingly, for all priming effects, a shift of the response time distribution was observed. Consequences for theories of morphological processing are discussed.

Evaluating Cognitive Action Control Using Eye-Movement Analysis: An Oculomotor Adaptation of the Simon Task

Cognitive action control has been extensively studied using conflict tasks such as the Simon task. In most recent studies, this process has been investigated in the light of the dual route hypothesis and more specifically of the activation-suppression model using distributional analyses. Some authors have suggested that cognitive action control assessment is not specific to response modes. In this study we adapted the Simon task, using oculomotor responses instead of manual responses, in order to evaluate whether the resolution of conflict induced by a two-dimensional stimulus yielded similar results to what is usually reported in tasks with manual responses. Results obtained from 43 young healthy participants revealed the typical congruence effect, with longer reaction times (RT) and lesser accuracy in the incongruent condition. Conditional accuracy functions (CAF) also revealed a higher proportion of fast errors in the incongruent condition and delta plots confirmed that conflict resolution was easier, as the time taken to respond increased. These results are very similar to what has been reported in the literature. Furthermore, our observations are in line with the assumptions of the activation-suppression model, in which automatic activation in conflict situations is captured in the fastest responses and selective inhibition of cognitive action control needs time to build up. Altogether, our results suggest that conflict resolution has core mechanisms whatever the response mode, manual or oculomotor. Using oculomotor responses in such tasks could be of interest when investigating cognitive action control in patients with severe motor disorders.

Estimating the divergence point: a novel distributional analysis procedure for determining the onset of the influence of experimental variables

The divergence point analysis procedure is aimed at obtaining an estimate of the onset of the influence of an experimental variable on response latencies (e.g., fixation duration, reaction time). The procedure involves generating survival curves for two conditions, and using a bootstrapping technique to estimate the timing of the earliest discernible divergence between curves. In the present paper, several key extensions for this procedure were proposed and evaluated by conducting simulations and by reanalyzing data from previous studies. Our findings indicate that the modified versions of the procedure performed substantially better than the original procedure under conditions of low experimental power. Furthermore, unlike the original procedure, the modified procedures provided divergence point estimates for individual participants and permitted testing the significance of the difference between estimates across conditions. The advantages of the modified procedures are illustrated, the theoretical and methodological implications are discussed, and promising future directions are outlined.

More than meets the eye: age differences in the capture and suppression of oculomotor action

Salient visual stimuli capture attention and trigger an eye-movement toward its location reflexively, regardless of an observer’s intentions. Here we aim to investigate the effect of aging (1) on the extent to which salient yet task-irrelevant stimuli capture saccades, and (2) on the ability to selectively suppress such oculomotor responses. Young and older adults were asked to direct their eyes to a target appearing in a stimulus array. Analysis of overall performance shows that saccades to the target object were disrupted by the appearance of a task-irrelevant abrupt-onset distractor when the location of this distractor did not coincide with that of the target object. Conditional capture function analyses revealed that, compared to young adults, older adults were more susceptible to oculomotor capture, and exhibited deficient selective suppression of the responses captured by task-irrelevant distractors. These effects were uncorrelated, suggesting two independent sources off age-related decline. Thus, with advancing age, salient visual distractors become more distracting; in part because they trigger reflexive eye-movements more potently; in part because of failing top-down control over such reflexes. The fact that these process-specific age effects remained concealed in overall oculomotor performance analyses emphasizes the utility of looking beyond the surface; indeed, there may be more than meets the eye.

Distributional benefit analysis of a national air quality rule

Under Executive Order 12898, the U.S. Environmental Protection Agency (EPA) must perform environmental justice (EJ) reviews of its rules and regulations. EJ analyses address the hypothesis that environmental disamenities are experienced disproportionately by poor and/or minority subgroups. Such analyses typically use communities as the unit of analysis. While community-based approaches make sense when considering where polluting sources locate, they are less appropriate for national air quality rules affecting many sources and pollutants that can travel thousands of miles. We compare exposures and health risks of EJ-identified individuals rather than communities to analyze EPA's Heavy Duty Diesel (HDD) rule as an example national air quality rule. Air pollutant exposures are estimated within grid cells by air quality models; all individuals in the same grid cell are assigned the same exposure. Using an inequality index, we find that inequality within racial/ethnic subgroups far outweighs inequality between them. We find, moreover, that the HDD rule leaves between-subgroup inequality essentially unchanged. Changes in health risks depend also on subgroups' baseline incidence rates, which differ across subgroups. Thus, health risk reductions may not follow the same pattern as reductions in exposure. These results are likely representative of other national air quality rules as well.

Comparing distributions of environmental outcomes for regulatory environmental justice analysis

Economists have long been interested in measuring distributional impacts of policy interventions. As environmental justice (EJ) emerged as an ethical issue in the 1970s, the academic literature has provided statistical analyses of the incidence and causes of various environmental outcomes as they relate to race, income, and other demographic variables. In the context of regulatory impacts, however, there is a lack of consensus regarding what information is relevant for EJ analysis, and how best to present it. This paper helps frame the discussion by suggesting a set of questions fundamental to regulatory EJ analysis, reviewing past approaches to quantifying distributional equity, and discussing the potential for adapting existing tools to the regulatory context.

Category induction via distributional analysis: Evidence from a serial reaction time task

Category formation lies at the heart of a number of higher-order behaviors, including language. We assessed the ability of human adults to learn, from distributional information alone, categories embedded in a sequence of input stimuli using a serial reaction time task. Artificial grammars generated corpora of input strings containing a predetermined and constrained set of sequential statistics. After training, learners were presented with novel input strings, some of which contained violations of the category membership defined by distributional context. Category induction was assessed by comparing performance on novel and familiar strings. Results indicate that learners develop increasing sensitivity to the category structure present in the input, and become sensitive to fine-grained differences in the pre- and post-element contexts that define category membership. Results suggest that distributional analysis plays a significant role in the development of visuomotor categories, and may play a similar role in the induction of linguistic form-class categories.