Service Cascade Research Articles

The impact of the opioid crisis on U.S. state prison systems

BackgroundPrior studies have documented limited use of medications to treat opioid use disorders (OUD) for people incarcerated within state prisons in the United States. Using the framework of the criminal justice OUD service cascade, this study interviewed representatives of prison systems in states most heavily impacted by opioid overdose regarding the provision of medications for OUD (MOUD). MethodsA stratified sampling strategy included states with high indicators of opioid-overdose deaths. Two sampling strata targeted states with: 1) OUD overdose rates significantly higher than the per capita national average; or 2) high absolute number of OUD overdose fatalities. Interviews were completed with representatives from 21 of the 23 (91%) targeted states in 2019, representing 583 prisons across these states. Interviews assessed service provision across the criminal justice OUD service cascade, including OUD screening, withdrawal management, MOUD availability and provision, overdose prevention, re-entry services, barriers, and needs for training and technical assistance.ResultsMOUD (buprenorphine, methadone, or naltrexone) was available in at least one prison in approximately 90% of the state prison systems and all three medications were available in at least one prison in 62% of systems. However, MOUD provision was limited to subsets of prisons within these systems: 15% provided buprenorphine, 9% provided methadone, 36% provided naltrexone, and only 7% provided all three. Buprenorphine and methadone were most frequently provided to pregnant women or individuals already receiving these at admission, whereas naltrexone was primarily used at release. Funding was the most frequently cited barrier for all medications.ConclusionStudy findings yield a complex picture of how, when, and to whom MOUD is provided across prisons within prison systems in states most heavily impacted by opioid overdose in the United States and have implications for expanding availability.

Environmental compensation for biodiversity and ecosystem services: A flexible framework that addresses human wellbeing

Environmental compensation should address negative impacts from human activities on nature, including loss of biodiversity and ecosystem services. However, successful compensation, achieving no net loss, requires broad quantitative information on different types of losses and gains. We find that the scope of compensatory schemes varies in what is considered compensable, which makes it challenging to apply a conceptual approach consistently across schemes with different needs. We propose a flexible yet structured framework for determining which values should be compensated and how. Our framework focuses specifically on habitat deterioration and is illustrated with a case study involving loss of eelgrass habitat. The framework helps identify compensation needs and selects among suitable compensation options, merging science-based information with normative issues and local concerns. By integrating the ecosystem services cascade model, it encompasses aspects from biodiversity structure to human wellbeing. The framework prefers in-kind compensation because this targets the structure level and thus meets compensation needs in all subsequent levels of the cascade model; further, it is more likely to capture non-instrumental values (i.e. in nature) and reduce exposure to uncertainty. We highlight the importance of spatial aspects of ecosystem functions, services and their subsequent impacts on wellbeing. Although our selection hierarchy assumes a “similar and nearby” principle for habitat restoration (preference for in-kind/on-site), this criterion is not universal. We underscore the hierarchy’s implicit normative assumptions and suggest that apparent disagreement about who should benefit may be traced to an unresolved conflict between egalitarianism and utilitarianism.

The resource service cascade: A conceptual framework for the integration of ecosystem, energy and material services

Sustainable resource use can be approached from a service perspective, via ecosystem services, energy services or material services. In this paper, we propose an overarching conceptual framework, with which to combine all three service theories and practices. To do this, we review and adapt Potschin and Haines-Young's ecosystem service cascade to create a “resource service cascade” and a classification system. By focusing on a resource's function in society rather than its source, we offer an alternative conceptualisation of the tangible aspects of what an ecosystem and socioeconomic system can provide human populations. We rework various definitions to overcome some of the challenges that emerge when accounting for either natural processes or socioeconomic processes but never both simultaneously. To demonstrate how the resource service cascade works conceptually, we highlight the contributions of resources when used in an illumination system/structure through to visual comfort (the service), need satisfiers and some tangible aspects of wellbeing. Future research, in the form of case studies, is required to operationalise the resource service cascade so that its usefulness can be empirically tested.

Proposing an ecosystem services-based framework to assess sustainability impacts of maritime spatial plans (MSP-SA)

This article contributes to the accelerating development of methods for sustainability assessment (SA) to support maritime spatial planning (MSP), by proposing an ecosystem services based framework for SA. MSP is generally seen as an important approach to promote a more sustainable use of sea space. However, so far all sustainability concerns are not equally well represented in planning practise; in particular, social sustainability aspects such as social justice and sociocultural values related to human-nature connectedness receive less attention. We first explored concepts and principles related to sustainability assessment and social sustainability in the scientific literature. Based on this, we analysed how far the present approaches to assessments in Baltic Sea EU Member States have been extended from environmental concerns to towards broader sustainability concerns so far. Using current best practise in two pioneering countries (UK and Sweden), we illustrated how social sustainability principles could match with applied social impact criteria, and further, how such criteria can inform an ecosystem services-based impact assessment framework. Based on existing frameworks, including the DPSIR (driving forces, pressures, state, impact, response) environmental assessment framework and the ecosystem service cascade, we propose a sustainability impact assessment framework for MSP (MSP-SA) integrating across sustainability dimensions and including assessment of distributional aspects of marine ecosystem service benefits. Finally, we discuss the applicability and further development of the framework in relation to present day sustainability assessment practise in MSP.

Research progress on the cascade effect of ecosystem service.

The ecosystem services cascade (ESC), which connects the components of ecosystem services with social value and builds a bridge between natural science and social science, can help decision-makers better integrate the concept of ecosystem services into decision-making. We reviewed the concept and the research progress of ESC. From the perspective of theory, the theoretical research of ESC mainly focused on how to accurately define each component and the causal relationship among different components, improve the practicability and applicability of ESC model, and how to effectively connect stakeholders and ecosystem service structure. From the perspective of application, ESC played an important role in ecosystem services mapping, ecosystem services assessment, and policy making. There were still great uncertainties in index selection and mutual feedback mechanism. Future research should be strengthened from the following aspects: to pay more attention to the structure process and classification standard of ecosystem services, to make up the lack of ESC of the feedback mechanism through multi-model fusion and regional survey, and to provide scientific guidance for human-earth coupling and sustainable development combined with regional characteristics .

The Missing Link(age): Multilevel Contributors to Service Uptake Failure Among Youths on Community Justice Supervision.

Youths in the juvenile justice system often do not access needed behavioral health services. The behavioral health services cascade model was used to examine rates of substance use screening, identification of substance use treatment needs, and referral to and initiation of treatment among youths undergoing juvenile justice system intake and to identify when treatment access is most challenged. Characteristics associated with identification of behavioral health needs and linkage to community services were also examined. Data were drawn from administrative records of 33 community justice agencies in seven states participating in Juvenile Justice-Translational Research on Interventions for Adolescents in the Legal System, funded by the National Institute on Drug Abuse (N=8,307 youths). Contributions of youth, staff, agency, and county characteristics to identification of behavioral health needs and linkage to community services were examined. More than 70% (5,942 of 8,307) of youths were screened for substance use problems, and more than half needed treatment. Among those in need, only about one-fifth were referred to treatment, and among those referred, 67.5% initiated treatment. Overall, <10% of youths with identified needs initiated services. Multivariable multilevel regression analyses revealed several contributors to service-related outcomes, with youths' level of supervision being among the strongest predictors of treatment referral. Community justice agencies appear to follow an approach that focuses identification and linkage practices on concerns other than youths' behavioral health needs, although such needs contribute to reoffending. Local agencies should coordinate efforts to support interagency communication in the referral and cross-system linkage process.

"You Cannot Catch Fish Near the Shore nor Can You Sell Fish Where There Are No Customers": Rethinking Approaches for Reaching Men With HIV Testing Services in Blantyre Malawi.

HIV testing is the entry point to the cascade of services within HIV care. Although Malawi has made positive strides in HIV testing, men are lagging at 65.5% while women are at 81.6%. This study explored the preferences of men on the avenues for HIV testing in Blantyre, Malawi. This was a descriptive qualitative study in the phenomenological tradition in seven public health facilities in Blantyre, Malawi, among men and health-care workers (HCWs). We conducted 20 in-depth interviews and held 14 focus group discussions among 113 men of varying HIV statuses. All our participants were purposively selected, and data were digitally recorded coded and managed through NVivo. Thematic analysis was guided by the differentiated service delivery model. Men reported a preference for formal and informal workplaces such as markets and other casual employment sites; social places like football pitches, bars, churches, and “bawo” spaces; and outreach services in the form of weekend door-to-door, mobile clinics, men-to-men group. The health facility was the least preferred avenue. The key to testing men for HIV is finding them where they are. Areas that can be leveraged in reaching men are outside the routine health system. Scaling up HIV testing among men will require targeting avenues and operations outside of the routine health system and leverage them to reach more men with services. This suggests that HIV testing and counseling (HTC) uptake among men may be increased if the services were provided at informal places.

Assessment of Prevalence and Cost of Care Cascades After Routine Testing During the Medicare Annual Wellness Visit

For healthy adults, routine testing during annual check-ups is considered low value and may trigger cascades of medical services of unclear benefit. It is unknown how often routine tests are performed during Medicare annual wellness visits (AWVs) or whether they are associated with cascades of care. To estimate the prevalence of routine electrocardiograms (ECGs), urinalyses, and thyrotropin tests and of cascades (further tests, procedures, visits, hospitalizations, and new diagnoses) that might follow among healthy adults receiving AWVs. Observational cohort study using fee-for-service Medicare claims data from beneficiaries aged 66 years and older who were continuously enrolled in fee-for-service Medicare between January 1, 2013, and March 31, 2015; received an AWV in 2014; had no test-relevant prior conditions; did not receive 1 of the 3 tests in the 6 months before the AWV; and had no test-relevant symptoms or conditions in the AWV testing period. Data were analyzed from February 13, 2019, to June 8, 2020. Receipt of a given test within 1 week before or after the AWV. Prevalence of routine tests during AWVs and cascade-attributable event rates and associated spending in the 90 days following the AWV test period. Patient, clinician, and area-level characteristics associated with receiving routine tests were also assessed. Among 75 275 AWV recipients (mean [SD] age, 72.6 [6.1] years; 48 107 [63.9%] women), 18.6% (14 017) received at least 1 low-value test including an ECG (7.2% [5421]), urinalysis (10.0% [7515]), or thyrotropin test (8.7% [6534]). Patients were more likely to receive a low-value test if they were younger (adjusted odds ratio [aOR], 1.69 for ages 66-74 years vs ages ≥85 years [95% CI, 1.53-1.86]), White (aOR, 1.32 compared with Black [95% CI, 1.16-1.49]), lived in urban areas (aOR, 1.29 vs rural [95% CI, 1.15-1.46]), and lived in high-income areas (aOR, 1.26 for >400% of the federal poverty level vs <200% of the federal poverty level [95% CI, 1.16-1.37]). A total of 6.1 (95% CI, 4.8-7.5) cascade-attributable events per 100 beneficiaries occurred in the 90 days following routine ECGs and 5.4 (95% CI, 4.2-6.5) following urinalyses, with cascade-attributable cost per beneficiary of $9.62 (95% CI, $6.43-$12.80) and $7.46 (95% CI, $5.11-$9.81), respectively. No cascade-attributable events or costs were found to be associated with thyrotropin tests. In this study, 19% of healthy Medicare beneficiaries received routine low-value ECGs, urinalyses, or thyrotropin tests during their AWVs, more often those who were younger, White, and lived in urban, high-income areas. ECGs and urinalyses were associated with cascades of modest but notable cost.

Patterns of Clinical Care Subsequent to Nonindicated Vitamin D Testing in Primary Care.

Exponential increases in nonindicated, low-value vitamin D testing have been reported over the past 15 years. Downstream effects of such testing have not been well quantified. The purpose of this study was to describe patterns of vitamin D testing within primary care of a large regional health system and to explore downstream health service utilization subsequent to nonindicated testing. Instances of vitamin D testing in 2015 were obtained by an electronic health record-automated search. A subset of patients for whom vitamin D testing was classified as nonindicated was identified, and vitamin D-related service utilization was tracked for 24 months. Of the 77,836 adult primary care patient records identified in 2015, vitamin D tests were conducted on 8,042 (10.3%), with 24.3% of tests yielding abnormal results. In the nonindicated test subset (n = 574), substantial clinical variability was illustrated by 85 care pathways and 26 vitamin D prescriptions. Forty-five percent of abnormal vitamin D lab tests were not followed up with repeat vitamin D tests. Vitamin D-related services (laboratory tests, imaging, and prescriptions) occurred at an average rate of 1.6 services per patient during the 24 months following nonindicated vitamin D testing. Some of these services were also classified as nonindicated. Evidence of a health service cascade following nonindicated vitamin D testing exists. Opportunities for improved consistency and quality of care related to vitamin D were observed in our health system. These results may inform clinical pathways related the prevention, evaluation, and treatment of low vitamin D.

Establishing the links between marine ecosystem components, functions and services: An ecosystem service assessment tool

Although the concept of ecosystem services has been in use for many decades, its application for policy support is limited, particularly with respect to marine ecosystems. Gaps in the assessments of ecosystem services supply prevent its empirical application. We advance these assessments by providing an assessment tool, which links marine ecosystem components, functions and services, and graphically represents the assessment process and its results. The tool consists of two parts: (i) a matrix following the ecosystem services cascade structure for quantifying the contribution of ecosystem components in the provision of ecosystem services; (ii) and a linkage diagram for visualising the interactions between the elements. With the aid of the Common International Classification of Ecosystem Services (CICES), the tool was used to assess the relative contribution of a wide range of marine ecosystem components in the supply of ecosystem services in the Latvian marine waters. Results indicate that the tool can be used to assess the impacts of environmental degradation in terms of ecosystem service supply. These impacts could further be valued in socioeconomic terms, as change in the socioeconomic values derived from the use of ecosystem services. The tool provides an opportunity for conducting a holistic assessment of the ecosystem service supply and communicating the results to marine spatial planning practitioners, and increasing their understanding and use of the ecosystem service concept.

Give the community the tools and they will help finish the job: key population-led health services for ending AIDS in Thailand.

Give the community the tools and they will help finish the job: key population-led health services for ending AIDS in Thailand.

Testing Positive and Disclosing in Pregnancy: A Phenomenological Study of the Experiences of Adolescents and Young Women in Maseru, Lesotho.

The routine antenatal screening through the prevention of mother to child transmission of HIV (PMTCT) services results in pregnancy being often the point at which an HIV diagnosis is made. Disclosure to partners presents particular complexities during pregnancy. However, research on the pattern and experiences of disclosure in pregnancy is limited in Lesotho, despite the high prevalence of HIV among pregnant women. The aim of this study was to explore and describe the disclosure experiences of adolescent girls and young women (AGYW) after receiving a positive HIV test result during pregnancy. Methods. Descriptive phenomenology using semistructured in-depth interview was used to collect data from AGYM sampled purposively from PMTCT sites located in urban areas of Maseru, Lesotho. Data analysis was inductive and followed the thematic approach. Findings. There were 15 AGYW involved in this study with the mean age of 20 years. Fourteen reported being pregnant with their first child and perceived HIV testing in antenatal care as compulsory. Ten AGYM disclosed their HIV status in the immediate posttesting period to protect their partners from HIV infection. The narratives revealed that the AGYM hoped that after disclosing, the partner would be tested for HIV. Furthermore, the AGYM disclosed because they wanted freedom to take their medication. Their experience of disclosure was relief, as they did not have to hide their HIV status. The AGYM reported being supported to adhere to medication and clinic attendance by their partners who also provided emotional support to them to deal with being HIV positive and pregnant. Conclusion. The AGYM recounted an overall positive experience of disclosure to their partners who agreed to test for HIV and adopted safe sex practices. This has positive implications for the PMTCT programme and the involvement of men in reproductive health. Therefore, there is need to integrate disclosure and partner testing interventions in the cascade of services in PMTCT programmes.

Access to prevention of mother-to-child transmission of HIV along HIV services cascade through integrated active case management in 15 operational districts in Cambodia.

IntroductionFollowing the introduction of option B+ in 2013, and with the perspective of eliminating mother‐to‐child transmission of HIV by 2025, Cambodia has implemented an integrated active case management (IACM) approach since 2014 to improve the notification and follow‐up of all HIV‐infected cases including pregnant women, and to ensure access to and use of the full prevention of mother‐to‐child transmission (PMTCT) service package by HIV‐infected pregnant women and their HIV‐exposed infants. This study aimed to analyse PMTCT cascade data in 15 operational districts (ODs) implementing the IACM approach in Cambodia.MethodsWe analysed PMTCT cohort data from 15 ODs implementing IACM approach between 1 January 2014 and 31 December 2016. We measured key indicators along the PMTCT cascade and compared them to available (cross‐sectional) PMTCT indicators during the 2011 to 2013 period.ResultsDuring the period 2014 to 2016, among 938 identified HIV‐infected pregnant women, 308 (32.8%) were tested HIV positive during their pregnancy, 9 (1.0%) during labour, while the remaining 621 (66.2%) were women on antiretroviral therapy (ART) who became pregnant. During the study period, 867 (92.4%) of the 938 women received ART during pregnancy and labour. Subsequently, 456 (85.6%) of the 533 HEI born and alive during the study period received 6‐week antiretroviral (ARV) prophylaxis, 390 (76.6%) and 396 (77.8%) of the 509 infants aged six weeks or older received cotrimoxazole prophylaxis and HIV‐DNA PCR test respectively. Among the 396 HEI who received HIV‐DNA PCR test, 7 (1.8%) were found HIV positive. The comparison with cross‐sectional PMTCT indicator obtained during the previous 2011 to 2013 period in the same 15 ODs, showed a significant increase in ARV uptake among HIV‐infected pregnant women (from 72.3% to 92.4%), in cotrimoxazole uptake (from 41.6% to 73.2%), and in HIV‐DNA PCR testing coverage among HEI (from 41.2% to 74.3%).ConclusionsThe implementation of option B+ and IACM may have contributed to the improvement of the PMTCT cascade in Cambodia. However, some gaps in accessing PMTCT services along the HIV cascade persist and need to be addressed.

Economic valuation of ecosystem services for the sustainable management of agropastoral dams. A case study of the Sakabansi dam, northern Benin

Abstract Agro-pastoral dams are multiple purpose water reservoirs primarily constructed to help pastoralists and riparian farmers address water shortages in rural areas. These dams are often surrounded by a buffer zone intended to minimize sedimentation and evapotranspiration. In spite of the importance of these dams for riparian communities’ livelihoods, their sustainability is nowadays challenged by various management issues underlined by stakeholders’ perception and valuation of ecosystem services provided by the dam system (reservoir-buffer zone). Taking the agro-pastoral dam of Sakabansi village in northern Benin as a case study, we assessed, quantified and valued both actual and potential benefits derived by riparian communities from the dam system using the ecosystem services cascade model as a conceptual framework. The Aggregated Economic Value of services provided by the dam system was estimated to 128,166 € based on nine ecosystem services. Fishery activities, despite causing conflicts between two major stakeholders of the dam, represented less than 0.09% of the Aggregated Economic Value. This suggests the crucial need to raise communities’ awareness on the economic value of various other benefits they derived from the dam system in order to facilitate a more comprehensive assessment of benefits and costs. We finally discussed the relevance of our valuation outputs in analysing trade-offs among services and in fostering stakeholder dialogues to inform land allocation and management at the local scale.

Towards integrating the ecosystem services cascade framework within the Life Cycle Assessment (LCA) cause-effect methodology

The assessment of ecosystem services (ES) is covered in a fragmented manner by environmental decision support tools that provide information about the potential environmental impacts of supply chains and their products, such as the well-known Life Cycle Assessment (LCA) methodology. Within the flagship project of the Life Cycle Initiative (hosted by UN Environment), aiming at global guidance for life cycle impact assessment (LCIA) indicators, a dedicated subtask force was constituted to consolidate the evaluation of ES in LCA. As one of the outcomes of this subtask force, this paper describes the progress towards consensus building in the LCA domain concerning the assessment of anthropogenic impacts on ecosystems and their associated services for human well-being. To this end, the traditional LCIA structure, which represents the cause-effect chain from stressor to impacts and damages, is re-casted and expanded using the lens of the ES ‘cascade model’. This links changes in ecosystem structure and function to changes in human well-being, while LCIA links the effect of changes on ecosystems due to human impacts (e.g. land use change, eutrophication, freshwater depletion) to the increase or decrease in the quality and/or quantity of supplied ES. The proposed cascade modelling framework complements traditional LCIA with information about the externalities associated with the supply and demand of ES, for which the overall cost-benefit result might be either negative (i.e. detrimental impact on the ES provision) or positive (i.e. increase of ES provision). In so doing, the framework introduces into traditional LCIA the notion of “benefit” (in the form of ES supply flows and ecosystems' capacity to generate services) which balances the quantified environmental intervention flows and related impacts (in the form of ES demands) that are typically considered in LCA. Recommendations are eventually provided to further address current gaps in the analysis of ES within the LCA methodology.

Perceived quality of HIV care and client satisfaction across different service providers in Ukraine.

Prior studies have shown that high client satisfaction and quality of services are important drivers of uptake and retention in human immunodeficiency virus (HIV) care. Study objectives were to assess the perceived quality of HIV services, satisfaction and associated factors across different types of health facilities in Ukraine. We conducted a cross-sectional study among 649 individuals receiving HIV services across 47 health facilities in three regions of Ukraine. Primary outcomes were satisfaction and perceived quality of services measured along five dimensions: accessibility, user-friendliness, privacy and confidentiality, comprehensiveness (separately for testing and treatment services). Quality dimensions were constructed by confirmatory factor analysis. Links between quality dimensions, satisfaction and related factors were measured by structural equation modelling. Median scores for accessibility, user-friendliness, privacy and confidentiality, comprehensiveness of services and overall satisfaction ranged from 0.75 to 1 out of 1. User-friendliness was the main determinant associated with satisfaction (total effect: β = 0.515, P < 0.001). Satisfaction was higher at primary healthcare centres (direct effect: β = 0.145, P < 0.001; indirect effect through accessibility: β = 0.060, P < 0.001), narcological/tuberculosis dispensaries (direct effect: β = 0.105, P = 0.006; indirect effect through accessibility: β = 0.060, P < 0.001) and hospitals (indirect effects through user-friendliness and accessibility: β = 0.180, P < 0.001) when compared to acquired immune deficiency syndrome centres. User-friendliness is a key driver of client satisfaction with HIV services in Ukraine. Decentralization of services, together with improved training and supervision for provider-client interactions may provide important levers to improve client satisfaction with HIV services and enrolment and retention in the cascade of HIV services.

Juvenile justice systems of care: results of a national survey of community supervision agencies and behavioral health providers on services provision and cross-system interactions

BackgroundYouth involved in the juvenile justice (JJ) system have high needs for behavioral health services, especially related to substance use and mental disorders. This study aimed to understand the extent to which elements in the cascade model of behavioral health services for JJ-involved youth are provided to youth by Community Supervision (CS) and/or Behavioral Health (BH) providers. In order to understand interactions across CS and BH systems, this study used a multistage probabilistic survey design to sample CS agencies and their primary BH service providers of substance use and mental health treatment in the United States. Parallel surveys were administered to both CS and BH providers regarding: characteristics of youth served, BH services available, whether services were provided directly and/or by referral, use of evidence-based practices (EBPs), and methods of collaboration, referral, and information exchange across CS and BH providers.ResultsThe findings from weighted national estimates demonstrate that youth referred from CS to the BH programs represent a more severe sub-group of youth under CS supervision. There are established cross-system relationships for assessment and referral for substance use and mental health treatment, but less so for prevention services. Most CS programs refer youth to BH providers for these services, which typically utilize more highly trained staff to provide EBPs to a majority of the youth served. More intensive substance use and mental health treatment, aftercare, and recovery support services were limited in availability.ConclusionsThe findings suggest that although many elements in a cascade model of BH services for JJ-involved youth have been implemented within local systems of care through collaboration between CS and BH providers, there are several underdeveloped areas and potential for attrition across the service cascade. Greater attention to providing services to youth with higher levels of severity, aftercare services, and recovery support is warranted within a multi-systemic framework.

Conceptualizing energy services: A review of energy and well-being along the Energy Service Cascade

The concept of energy services is used in different contexts and scientific fields mainly to emphasize that it is the services provided by energy rather than energy carriers that people demand and that generate well-being. While the value of the concept is widely acknowledged, there are remarkable differences in how energy services are conceptualized.This article proposes the ‘Energy Service Cascade’ (ESC) as a conceptual framework aimed at clarifying and bridging different approaches. The ESC is inspired by Haines-Young’s and Potschin’s (2011) ‘Ecosystem Service Cascade’, which distinguishes: a) structures, b) functions, c) services, d) benefits and e) values. When used to systematize the debates around energy services, we argue that these differentiations reflect a) energy conversion chains comprising natural structures, human-made capital and labor; b) physical functions performed by energy chains; c) services humans demand to foster well-being; d) the actual contributions to human well-being (health, life satisfaction, …); e) individual preferences and attitudes that create willingness to pay, encourage business models, etc. ‘Values’ influence how services and benefits are perceived and affect ‘structures’ through various mechanisms (investment decisions, environmental and economic policy, …).To showcase the usefulness of the ESC as conceptual framework, we provide a review of literature to reveal the differing scopes of four main contexts in which energy services are being studied. We call them ‘energy chain context’, ‘energy demand context’, ‘well-being context’ and ‘entrepreneurial context’. Given the diversity of how energy services are interpreted and the various scopes and research aims, a full harmonization of concepts seems out of reach. Nevertheless, a more unified understanding of what is considered as ‘service’ and differentiation from ‘functions’ and ‘benefits’, as provided by the ESC, could be a first step towards more systematic terminology and may support interaction between the different discourses.

Socio-economic inequalities in hypertension burden and cascade of services: nationwide cross-sectional study in Nepal.

With an aim to examine the socio-economic inequalities in prevalence, awareness, treatment, and control of hypertension, this study analyzed 14,823 adults, 15 years or older with blood pressure measured, in the 2016 Nepal Demographic Health Survey. Multi-variable logistic regression and Lorenz curves were used to explore the inequalities. The prevalence of hypertension was 19.5% (95% CI: 18.3-20.7). Further, of the total hypertensive, the prevalence of hypertension awareness, treatment and control was 40.0% (95% CI: 37.5-42.6), 20.2% (95% CI: 18.0-22.2) and 10.5% (95% CI: 8.8-12.2), respectively. Participants with secondary (OR: 1.45, 95% CI: 1.20-1.76) and higher education (OR:1.42, 95% CI: 1.10-1.83), compared to those with no education/preschool, and those in urban residency (OR: 1.28, 95% CI: 1.09-1.50) compared to rural areas, and in province-4 (OR: 1.50, 95% CI: 1.14-1.96) and province-5 (OR: 1.34, 95% CI: 1.04-1.72), compared to province-1, had higher odds of being hypertensive. Household wealth status showed a positive association with prevalence, awareness, and treatment of hypertension (p-trend < 0.001). Those from richest category were 1.7 times more likely to be hypertensive, were more aware of hypertension (3.2 times), received treatment (5.1 times), and had controlled hypertension (1.6 times), compared to the poorest category. Adjusting for body mass index, completely ameliorate the effect on hypertension prevalence (p-trend = 0.57) and altered nominally awareness (p-trend < 0.0001), treatment (p-trend < 0.0001), and control (p-trend = 0.099). Urban hypertensive females, at the lowest wealth quintile, received poor care services; only 12% were aware of their hypertension status, 7% received treatment, and only 4% had controlled hypertension. These socio-economic inequalities warrant interventions aiming at preventing hypertension and increasing coverage of services for those higher at risk. Future studies need to explore socio-economic and geographic disparities in disease burden and cascade of services.

Progress and Challenges of Implementing Decentralized HIV Testing For Prevention of Mother-to-Child Transmission of HIV - Myanmar.

Background:Myanmar has adopted point-of-care (POC) HIV testing for its prevention of mother-to-child transmission of HIV program, and was initiated in 84 townships in 2013. This study assessed the progress of HIV testing uptake from 2012, one year prior to POC testing, to 2015, and the challenges faced by service providers during the rapid rollout of this testing strategy.Methods:This serial cross-sectional study included 23 townships randomly selected from the 84 townships. An open-question survey was used to collect information on the challenges faced by service providers. A random effects logistic model was used for assessing the progress of HIV testing uptake among urban and rural health center groups.Results:HIV testing uptake for antenatal care (ANC) attendees increased from 60% to 90% for rural and from 70% to 90% for urban attendees. The proportion of ANC attendees who were tested at their first visit increased from 70% to 80% for rural and from 70% to 90% for urban attendees. In addition, the proportion receiving same-day test results increased from less than 10% to 90% for both groups. Major challenges faced during the initial rollout included low health awareness among pregnant women, fear of stigma and discrimination, long travel times and costs, and increased workloads of providers in rural settings.Conclusions and Global Health Implications:The program should consider recruiting local volunteers to help reduce the workloads of service providers. Professional education based on need and continued mentoring and quality control schemes for HIV testing need to be in place. This decentralized strategy would be applicable to other resource-limited countries.