Social capital critical appraisal example

For the class this week, please read the two articles and prepare the following discussion topics.

For each article,

1. What is the definition of social capital? What are the differences between individual-level social capital and commuity-level social capital? 

2. How did the study measure social capital? (i.e., what is the unit of analysis? what are the items they used to measure social capital?)

3. What are the study results? Please read the tables and figures and discuss the findings.

4. What are the study limitation and policy implications?

 

 

	YCC1	YCC2
Definition	SC is a conceptual tool that offers insights into social determinants of health.	Social capital is relational, and based on the resources people can access through others.
Individual vs community level	Individual social capital refers to concepts such as one’s network size, frequency of interpersonal communication, and informal social engagement. Social capital measured at the contextual level refers to resources available via membership in a broader community.	Individual approach emphasizes individuals’ experienced situations, and how they perceive the access they and their family have to certain resources through their social network. Studying group level social capital aggregates the individual perceptions of social capital to a contextual level. The group level measure emphasizes how being part of a larger social structure can affect individual health behavior.
Unit of analysis	Individual County	Individual Neighborhood
Items used	Individual social capital: neighborhood trust (“Generally speaking, would you say that you can trust all the people, most of the people, some of the people, or none of the people in your neighborhood?“), neighbor interaction (“In the past month, how often did you talk with any of your neighbors?“), civic engagement/volunteering (“In the past month, did you spend any time volunteering for any organization or association, or not?“), and remote contact with family and friends (“In the past month, how often did you communicate with friends and family by phone, text, email, app, or using the Internet?“).   County-level social capital is measured using aggregated individual-level survey responses and the U.S. government-sponsored Social Capital Index (SCI) consisting of 4 subindices and 10 variables (in parentheses below) based on data from various sources collected between 2006 and 2016, primarily from 2013 forward: family-unity (% births to unmarried women; % women currently married; % children with single parent), community-health (non-religious non-profit organizations per 1000; religious congregation per 1000; informal social engagement subindex), and institutional-health (Presidential election voting rate 2012 & 2016; mail-back census response rate; confidence in institutions subindex), and “collective efficacy” (violent crimes per 10,000).	Individual level social cohesion “How many of your neighbors know which family you belong to (know where you live)?” “Do your parents often talk about how the neighbors’ children are doing at school?“ “Do you hang out or do other activities with your neighbors?“ “Does your family hang out or do other activities with other families in your neighborhood?”   Social cohesion on the neighborhood level 4 from individual plus 3: “Do you like the environment of your neighborhood?”  “How many people in your neighborhood do you think know each other?” “Do you think people in your neighborhood are willing to help others or do they only care about themselves?”
Study results (main findings)	Informal-structural social capital (neighbor-interactions) negatively moderates the impact of restrictions; however, neither formal-structural (volunteering), cognitive (neighbor-trust), nor strong-tie social capital buffer restrictions.   After adjusting models for individual-level social capital, county social capital exerts independent-effects on psychological distress.   After adjusting for individual-level social capital, no dimension of contextual social capital is associated with the outcome.   Suggesting restrictions have a stronger positive association with psychological distress among individuals in high social capital counties. Among individuals in low social capital counties, restrictions have no association with distress. Benefit of living in high social capital counties declines as restrictions increase.   Conclusion: individuals’ social capital, especially neighbor connectivity, may moderate the harm that pandemic-related restrictions have on mental health.	Individual level neighborhood social capital is related to their baseline health status, but not to changes in health status. Only neighborhood level social capital is related to changes in health status. More social capital in the neighborhood is related to positive changes in health status.   People may not be totally conscious of the fact that they are being part of a larger structure, such as a neighborhood, and experiencing the benefits from that structure.
Limitations	Reverse causality, risks of false positives.	Relation between social capital and health status should be interpreted with caution.
Policy implications	Neighbor connectivity should be improved.	Awareness of the level of community-level social capital should be improved.

  

AMR Critical Appraisal Example

Q1: What’s your suggestions to improve the scientific background and rationale for the investigation being reported in the introduction section?

A:

-          It is lacking data about AMR as a problem right now (prevalence, mortality rate, etc), they only show the future burden of the conditions. à They should present both actual burden and potential burden.

-          Not presenting clear correlation of knowledge and practice of antibiotic use to actual AMR prevalence. à They should give convincing evidence that knowledge and practice of antibiotic use is affecting the actual case of AMR.

 

Q2: Is there any flaw(s) in the table 3 for the interaction effect?

A:

-          The wide 95% CI of “Interaction between Knowledge of AMR and 35–49 Years Old” and “Interaction between Knowledge of AMR and 21–34 Years Old”.

-          Perhaps it is caused by very imbalance data regarding “Knowledge of AMR”, as we know that only 3% of respondents were considered having good knowledge.

 

Q3. Is there any flaw(s) in the table 4 (also in the table5) for the interaction effect?

A:

-          If only for the interaction effect it seems no flaws, but when we see for each age group, we can see that some age groups showed wide 95% CI. And it was getting wider as the age group being younger.

-          We should aware that younger respondents tend to having inappropriate use of antibiotics. The author did not mention specifically about this issue, they just focusing on the effect size.

 

Q4 If the authors got results from 18-49-year-old female subjects indicated that good accessibility to primary care could reduce the risk of self-medication (one of the inappropriate use of antibiotics), please illustrate your potential explanation(s) with supportive references.

A:

-          In that scenario, 18-49-year-old female having less access (compared to male and older age groups) is contra-intuitive, as female is assumed to be more time spent at home and older people tend to have more limitation on healthcare access. And regarding the paper, the access to primary care did not show as a problem, since most Singaporean get their antibiotic from primary care.

-          The potential explanation is more about women’s mobility, regardless of age group.

-          In the other setting, the explanation is also including the funding, but only when it related to hospital, not primary care since it involving intravenous antibiotic: “Patients who were female, aged 18 years or more (compared to those aged ≤5 years), received antibiotics intravenously and received financial assistance from an insurance scheme were more likely to be prescribed antibiotics inappropriately.”[1] It will be interesting to see the effect of health insurance as explanatory factor of better access for 18-49-year-old female will decrease the self-medication.

-          “This trend is observable in the data for HICs where lower education, less employment, and lower income leads to higher antibiotic use. However, the opposite is true for data from LMICs.”[2] We should also considering broader socioeconomic characteristic of the respondents to explain the finding.

 

Q5 What are the policy implications?

A:

-          Education on antibiotic should focused on younger population.

-          Since they mostly got the antibiotic from GP clinic and polyclinic (83%), so the primary clinics should be the place of promoting awareness about good antibiotic use and AMR.

 

Q6 Please provide at least two of your questions and your suggestions and comments for each question.

A:

-          Why the author set the cut-off point for “Knowledge of AMR” too high (8 out of 8 question should be right answered to be considered as “good”)? If they (at least) try to use different cut-off point, perhaps it will give a different conclusion. It is perhaps the biggest flaw in this paper, since only 3% of respondents were considered having good knowledge of AMR à the proportion between groups were highly imbalance. The author did not mention that they have tried something to solve this problem.

-          Why they were not using the knowledge score as continuous variables? Since there are no validated cut-off points for Singaporean, it is better to also treat the knowledge variables as continuous variables. The different approach with using the raw knowledge score without categorization can show if any association was existing in more sensitive manner.

 

 

References:

1.     Chang, Y., Chusri, S., Sangthong, R., McNeil, E., Hu, J., Du, W., Li, D., Fan, X., Zhou, H., Chongsuvivatwong, V. and Tang, L., 2019. Clinical pattern of antibiotic overuse and misuse in primary healthcare hospitals in the southwest of China. PLoS One, 14(6), p.e0214779.

2.     Schmiege, D., Evers, M., Kistemann, T. and Falkenberg, T., 2020. What drives antibiotic use in the community? A systematic review of determinants in the human outpatient sector. International journal of hygiene and environmental health, 226, p.113497. 

Photovoice to Improve Food Choices in Indonesian Elementary School Students

Indonesia is known to have a double burden of malnutrition. Underweight, stunting and overweight are arising in Indonesian children. Socioeconomic factors are not the primary source of problems since we can find malnutrition in children in families from middle-high socioeconomic levels.

Food choice is one factor contributing to these problems. Indonesian people love to eat fried foods and consume a high proportion of carbohydrates (mostly rice and sugary drinks). That is quite ironic since Indonesia has a good supply of fruits and vegetables and has many ways to cook instead of frying.

The problem of unhealthy food choices is somehow familial and inherited over generations. Efforts to develop healthier food choice programs to decrease malnutrition are complex because of familial, environmental, and cultural issues that must be addressed for efforts to succeed. So far, the program of improving food choices was focusing on the parents, especially the mothers. It is based on the fact that mothers usually provide family food. Even if the family did not cook by themselves, mothers took the responsibility to subscribe the food from local catering services or buy from nearby restaurants.

Children in elementary school should be involved in the movement to improve their food choices because they will get the most impact and hopefully will last to the next life stage. The curriculum in the school has been improved in the last few years, including a healthy diet and other healthy lifestyles. However, it is essential to know what the children really consume daily, relate it to their health condition, to understand how they view the importance of healthy food choices to benefit themselves in the long run.

We can ask elementary school students to show us their food choices using Photovoice. We first need to collaborate with the school to make sure the program aligns with their curriculum and not just giving extra works for the children and their families. It will be much easier in this post-pandemic teaching environment where the school is still keeping the online assignment system.

In the first session, we should inform the children and their parents about the programs, the goals, and getting their consent. To facilitate them taking pictures that are significant for them, we can provide support of mobile internet data voucher since nearly all families have the phone with camera. For families without a camera perhaps we can lend them a phone with camera. It is also important to share some basic ethics in documenting objects with a camera.

The project should be run daily for at least seven consecutive days; the longer, the better. Each day, they will be asked to submit 1-3 photos of their actual meal/snack or other aspects of their lives related to food (it could be the food they do not like or food advertisement that they love). At the end of the program, we ask each student to select two of the photos and write a reflection on them. This reflection part is also in line with the national education program that asked each Indonesian student to reflect (mainly after the given task of reading stories) to improve their literation.

In the second session, each student shared their two selected pictures and thoughts, providing us about the familial, environmental, and cultural context of food choices. We can also ask their parents to join this session to get their confirmation and feedback.

This method can be an insightful and fun way to initiate discussion in improving food choices. Since the daily photo collection spans at least a week, it is hard to make up what they really eat in each day’s photo. So, we can get a variety of food-related photos from a family and infer their family food choices.

Even if they showed the healthier food each day just to get a good impression because they know they are being “watched”, it is a promising finding. We can also ask about the feeling of switching to healthier food choices for one week and the barrier to keeping it as their new family tradition. For the families that are really good at their food choices, we can ask about their tips and tricks on doing that regularly.

If possible, the program should be held each semester or year. So we can make it a routine, helping students and families to improve over time. 

Emerging diseases in Indonesia

Indonesia has a large area and a very large population. There are also many types of emerging diseases in Indonesia. I will tell you about 2 emerging diseases that I often encountered before the Covid-19 pandemic. I worked as medical doctor in North Sulawesi, one of Indonesian places appointed to focus on emerging diseases: malaria and rabies.

Malaria is a disease that is easily found in North Sulawesi. Patients with fever will tend to be suspected of being malaria patients. The environment there is suitable as a breeding ground for mosquitoes because there are still many areas with dense vegetation. Also supported by high rainfall so that it is easy to find pools of water.

Rabies can be transmitted from various animals to human. However, in North Sulawesi, it is common to find rabies transmission from dogs. As an area that is dominated by Christians, there are many dogs, both domesticated and stray dogs. Rabies vaccinations for dogs there are still low. There are several cases of death of rabies patients, but they seem to have started to be controlled, because anti-rabies serum is quite easy to find there. 

Healthcare access and quality by level of healthcare spending (2000 to 2013): Timor Leste vs Maldives

Timor Leste and Maldives are both small island countries in Asia. Geographically, Maldives is more isolated than Timor Leste. Timor Leste's economy relies mostly on offshore oil and gas resources, and Maldives relies mostly on tourism and fisheries sectors. The total population of Timor Leste is more than twice of Maldives'. In 2013, the population of Timor Leste was 1,153,295 and of Maldives was 415,593. With a slightly higher growth rate in Timor Leste.

Healthcare access and quality by level of healthcare spending (2000 to 2013) show Timor Leste's differences compared to Maldives. Healthcare access and quality are measured by the Institute for Health Metrics and Evaluation HAQ Index. 32 causes considered amenable to health care comprise the HAQ Index, representing a range of health service areas:

·       vaccine-preventable diseases

·       infectious diseases

·       maternal and child health

·       non-communicable diseases

·       conditions from which surgery can easily avert death.

In 2000, the HAQ Index of Timor Leste was 38.2 and of Maldives was 59.3. In 2013, the HAQ Index of Timor Leste was 51.6 and of Maldives was 75.5. During the 13 years period, Maldives performs better in increasing the HAQ Index (16.2 points) than Timor Leste (13.4 points). We should also consider that Maldives' starting point is higher, which reflects the better infrastructure and health system available that essential to health care access and quality level.

In 2000, the healthcare expenditure per capita of Timor Leste was 45.23 and of Maldives was 274.25. In 2013, the healthcare expenditure per capita of Timor Leste was 96.32 and of Maldives was 1259.6. Maldives in 2013 spent about four-fold what it had in 2000 for healthcare, while Timor Leste only spent about two-fold. We can learn that it takes more resources per capita to maintain and increase the HAQ index. This will become more complicated when we have a larger population. As the newly recognized independent country, Timor Leste has done well.

References:

1.     https://data.worldbank.org/indicator/SP.POP.TOTL?end=2019&locations=TL-MV&start=2000&view=chart

2.     https://ourworldindata.org/grapher/haq-by-level-of-healthcare-spending-endpoints?time=2000..2013&country=MDV~TLS

3.     https://www.cia.gov/the-world-factbook/countries/maldives/

4.     https://www.cia.gov/the-world-factbook/countries/timor-leste/

https://healthsystemsfacts.org/comparisons-of-health-systems/healthcare-access-quality-index-overview/ 

ART application in Indonesia

Sini, et al. Blastocyst elective single embryo transfer improves perinatal outcomes among women undergoing assisted reproductive technology in Indonesia. Asian Pacific Journal of Reproduction 2020; 9(3): 118-123.

 

Summary of keypoints of ART application in Indonesia from the paper

IVF is not a new practice in Indonesia. Morula IVF Clinic is the largest fertility clinic in Indonesia.

Elective single embryo transfer (eSET) and double embryo transfer (DET) have become the two most implemented IVF practices worldwide, including in Indonesia. DET remains the most popular method used in IVF programs in Indonesia due to financial limitations, lack of understanding of the complications of multiple pregnancy, and patients’ preferences in conceiving twins.

The Indonesian infertile couples’ decision-making procedures in deciding the number of embryos to be transferred remained unknown. However, due to the lack of subsidies, ART’s overall cost to achieve a live birth may significantly impact the patients’ decision to prefer DET over eSET.

Comments

Indonesian people also see infertility as a serious health problem. It seems to have support from the government so that there is some clinic focused on fertility. The religious organization also sees this problem as a personal issue, so that I personally never heard or read about any religious organization go on strike to protest the fertility clinic. Some papers are available to lay the discourse of ethical or religious debate over the issue but not explicitly condemn the practices.

Financially, the Indonesian government is not subsidizing fertility procedures. Infertility is not the priority of the relevant ministry or public agency, mainly because Indonesia faces the more critical issue: high fertility rate, so the government focuses on family planning to reduce the national fertility rate.

Given that condition, it makes sense when the infertile couples prefer the procedure to put two embryos instead of only one. They want to improve the success rate, and perhaps they had calculated that the cost of getting twins (if both of the embryos transferred is successful) is much cheaper than redoing the whole procedure to get a total of two children.

Proposed research questions

1.     What is the impact of ART in the patients’ economy when the procedure was successful? (comparing the financial condition on the starting date of the program with the condition on the delivery, and following up in 1, 5, and 10 years after the delivery)

What is the impact of ART in the patients’ economy when the procedure was unsuccessful? (comparing the financial condition on the starting date of the program with the condition on the day when the program was declared unsuccessful, and following up in 1, 5, and 10 years after the that date) 

Character from The Lab

Character: Kim Park (Graduate Student)

 

Greg asked to sign the approval of the paper that put Kim as co-author. So, Kim told him that she needs to read it first. Kim found that the figure in the paper was falsified.

Kim asked for bits of advice from friends and her Mom, and further seek information from the university’s website and found information about RIO.

Kim eventually called RIO and explaining the situation, and she chose to reveal her name to the officer, Dr. Ridgley. Further, Kim met Dr. Ridgley and brought the things to support the allegation.

RIO did the work professionally. Even that Kim get some backlashes, she kept faith in them. The truth was then discovered, that Greg did the falsification. Kim’s act was like a hero that saved her lab. 

Designing a quasi-experimental study example

Describe your intervention content, experimental design, evaluation indicators, and analysis methods. Do not copy from existing papers.

 

You plan to provide health education intervention for community-based older adults about physical activity and nutrition. Please design a quasi-experimental study with a controlling group.

 

Answer:

Quality of life (QoL) was positively associated with handgrip strength (HGS). Two factors known as promoting factor of HGS are physical activity and nutrition. This study will measure the effect of health education intervention via videos about physical activity and nutrition to improve HGS.

 

Intervention content: PUGS (Indonesian Guidelines on Balanced Nutrition and Physical Activity). Every week from week-1 until week-5, the two interventional groups will get the short video (5-10 minutes) explaining about physical activity and nutrition based on PUGS guideline. The control groups just do their activities as usual.

The videos are 5 different videos with similar educational contents, all of them are made by the Indonesian Ministry of Health. The videos are played on the screen with LCD projector connected to a laptop.

 

Experimental design: Non-randomized controlled study.

We will select randomly 2 of all active Posyandu Lansia (where elderly regularly (monthly) come to get basic physical examination and health education) in District A. As a control, we will select randomly 2 of all active Posyandu Lansia in District B.

Most of Posyandu Lansia is consisted of 20-30 elderly, aged 60 years or more.

District A and District B are in the same City, but with a distance at least 10 kilometers.

Posyandu Lansia is categorized based on the record of regular activities on the previous year. Posyandu Lansia with 10 regular activities per year or more is considered as the active one.

 

Evaluation indicator: handgrip strength (HGS) on the 6^th month compared to the 1^st month done for all the elderly in four groups.

We will only analyze the data for the elderly that have twice measurements of HGS.

Handgrip strength were obtained by standard dynamometry. Measurements were carried out with the respondents standing, elbow flexed at 90° and with the forearm in neutral position. Each respondent carried out two measurements and the mean value for both hands was used for further statistical analysis.

 

Analysis method:

We will compare the mean of HGS in 5^th week and 1^st week for each group using paired t test.

We will compare the mean differences of HGS in interventional and control group using independent t test.

We also will analyze the number of video exposure in the interventional groups to see if there is 

Effect of chronic disease on body weight in elderly

IFLS-5

 

Are chronic diseases having impact on body weight?

·       Are there any differences of body weight of person with and without hypertension?

·       Are there any differences of body weight of person with and without diabetes mellitus?

·       Are there any differences of body weight of person with and without stroke?

·       Are there any differences of body weight of person with and without cancer?

·       Are there any differences of body weight of person with and without kidney disease?

 

Cross-sectional design.

 

Do you have the following chronic diseases?

a. Hypertension: 1. Yes 2. No

b. Diabetes mellitus: 1. Yes 2. No

c. Stroke: 1. Yes 2. No

d. Cancer: 1. Yes 2. No

e. Kidney disease: 1. Yes 2. No

 

Sex: 1. Male 2. Female

Age:    1. Non-elderly (18-60 years)

            2. Elderly (> 60 years)

Weight: (kg)

 

 

Variables	Persons	Mean (SD)
Weight

 

Variables	Persons	%
Sex Male Female
Age Non-elderly Elderly
Hypertension Yes No
Diabetes mellitus Yes No
Stroke Yes No
Cancer Yes No
Kidney disease Yes No

 

 

Using student’s t-test (or Mann-Whitney test)

	Hypertension
	Yes	No
Weight	Mean (SD)	Mean (SD)

 

	Diabetes mellitus
	Yes	No
Weight	Mean (SD)	Mean (SD)

 

	Stroke
	Yes	No
Weight	Mean (SD)	Mean (SD)

 

	Cancer
	Yes	No
Weight	Mean (SD)	Mean (SD)

 

	Kidney disease
	Yes	No
Weight	Mean (SD)	Mean (SD)

 

	Sex
	Male	Female
Weight	Mean (SD)	Mean (SD)

 

	Age
	Non-elderly	Elderly
Weight	Mean (SD)	Mean (SD)