Monthly Archives: December 2024

Dysregulation of Cell-Mediated Immunity in Patients with Long ICU Stay Affected of Multiple Organ Dysfunction Syndrome and Multifocal Candidiasis

DOI: 10.31038/IDT.2024523

Abstract

Introduction: The endogenous immunosuppression in critically ill patients with Multiple Organ Dysfunction Syndrome, requiring long-term ICU, can play an important role in the prognosis of Multifocal Candidiasis.

Method: Prospective study with control group (33 healthy volunteers) and study group (43 critically ill patients non neutropenic admitted to ICU with invasive mechanical ventilation), about cellular immunity in vitro, using Lymphoblastic Transformation Tests (LTT) stimulated with phytohemagglutinin (PHA). Simultaneously, the study group is followed up on appearance of Invasive Candidiasis and in vivo immunity study, using skin tests during the first week of ICU stay.

Results: There are significant statistical differences between the control group and the study group in relation to LTT PHA results. These differences are also found in the study group in relation to mortality and when skin tests are negative. When analysing the subgroup of patients with ICU stay longer than 12 days, there are statistically significant differences in LTT PHA when comparing the test performed in the 1st week in ICU in survivor patients with Invasive Candidiasis and the control group, but there are no differences with the 2nd determination. There are statistically significant differences when comparing the results of LTT PHA among patients with Invasive Candidiasis according to mortality in the 2nd determination, but these differences were not identified in the 1st week of ICU.

Conclusions: Both in vivo cellular immunity studies, using skin tests, and in vitro studies with the LTT PHA, help to establish a prognosis in critically ill patients with Multiple Organ Dysfunction Syndrome requiring long-term ICU care and in which a Multifocal Candidiasis has been identified. Monitoring of T-cell dysregulation and endogenous immunosuppression can help to identify patients who may benefit from new immunomodulatory therapeutic strategies.

Keywords

Cell-immunity, Multifocal candidiasis, Multiple organ dysfunction syndrome, Non-neutropenic, ICU

Introduction

In order to make Multifocal Candidiasis equivalent to Invasive Candidiasis, and thus initiate an early antifungal treatment to prevent death attributable to Candida spp. in non-neutropenic critical ICU patients who are neither neutropenic nor affected by AIDS [1,2], we analysed the factors that could contribute to the transformation from colonization of Candida spp. [2] to Multifocal Candidiasis and subsequent disseminated candidiasis. It is universally accepted that Candida spp. infections are linked to the antibiotic era [3]. The prolonged use of broad-spectrum antibiotics leads to an intestinal microbiological imbalance, promoting an excessive growth of candida in the intestinal lumen and thus facilitating the translocation of these fungi into the interior of the organism [4]. As an example, in the observations that were made, it was very common that, after treating with antibiotics treatment with broad-spectrum antibiotics for a sepsis due to Pseudomonas spp., if the patient survived and remained in critical condition, it was very common to detect the appearance of an invasive candidiasis. However, in these ICU patients who remain in a critical condition for a prolonged period of time (more than 7 days), other factors related to ICU treatment and monitoring can be identified, which should be considered as facilitators of Multifocal Candidiasis [5]:

  • Gastrointestinal dysfunction: Malnutrition and/or absence of enteral nutrition due to intestinal paresis; breakdown of the intestinal physiological barrier; treatment with parenteral nutrition, gastric protectors and prolonged nasogastric tube
  • Prolonged vesical catheterization
  • Prolonged arterial or venous catheter
  • Mechanical ventilation more than 7 days
  • Hemofiltration techniques

In some cases, this list can also be added treatment with prolonged treatment or high doses of corticosteroids (30% in these patients) [6]. It is at this point where it is questioned whether there may be in these patients an immunodeficiency acquired in the ICU and that this may play a role as important as the prolonged antibiotic treatment.

Methods and Materials

Prospective Study with Control Group

Study Group (43 patients): Patients over 18 years old and middle ages of 61 ± 10,8 (37-86), admitted to ICU with invasive mechanical ventilation without history of neutropenia or AIDS, and need for mechanical ventilation for more than 48h. There was no informed consent from the patients because their level of consciousness on admission to the ICU does not allow it. Family members have been informed about participation in the study, its risks and that this participation will not modify any of the protocols required in patient care throughout their stay in the ICU. Only the patients with the consent of their relatives have been included. Mortality rate of this study population was 46%. In 12 cases the UCI stay was lesser than 12 days with 42% mortality rate, and in 31 cases UCI stay was more than 12 days with a 48% mortality rate. The diseases that were the reason for ICU admission, grouped as follows were:

  • Chronic Obstructive Pulmonary Disease with respiratory failure requiring invasive mechanical ventilation prior to ICU admission (15 cases)
  • Postoperatory complicated cardiac or abdominal surgery with more than 24 h. of mechanical ventilation (12 cases)
  • Patients with Tetanus disease with invasive mechanical ventilation (13 cases).

Control Group (33 healthy volunteers): Group formed by subjects who have been informed prior to the acceptance of being included in this study.

Immunity Cellular Evaluation

  1. In vivo immunity study using skin tests, only in the study group. The test is considered positive if they present, at least in one of the puncture sites, an induration greater than 5 mm in diameter against the selected antigens (Streptokinase- Streptodornase 1/4, Candidin 1/500, P.P.D. 1/1000, Toxoplasmin). The test is performed during the first week of ICU stay and is not repeated at any other time.
  2. In vitro immunity study using Lymphoblastic Transformation Tests (LTT), lymphocyte extraction is performed in both Technique: An adjustment of lymphocytes to 2×106 cells/ ml is performed. Three control cultures and three stimulated with phytohemagglutinin (PHA) are grown for 72 h. at 37°C, with aerobic culture and 5% CO2. After this time, the slide extension and May-Grünwald, Giemsa staining is performed. Once the staining is done, the percentage of blasts over the total population of lymphocytes is calculated. This test, in the study group, is performed during the first 6 days of stay in the ICU and then every 12-17 days until discharge from the ICU.

Diagnosis of Multifocal Candidiasis

From the inclusion of the patients in the study group, cultures to identify Candida spp. are carried out once a week, until the ICU is discharged, to identify Candida spp. in five foci:

  1. Blood cultures
  2. Respiratory secretions from tracheobronquial aspiration
  3. Urinary cultures from closed circuit bladder catheterization. Positive only with more than 5000 colonies/ml.
  4. Simultaneous presence of positive cultures in the pharyngeal swab and in the gastric aspirate obtained through the nasogastric tube
  5. Other foci. Positive cultures from drainages or wound exudates

Candida colonization is defined when this study demonstrates the presence of Candida spp. in only one of these foci and the blood culture is negative. Candida multifocality or Invasive Candidiasis is defined when positive cultures are identified simultaneously in two or more of these foci and/or positive blood cultures.

Variables and Statistical Analysis Methodology

The following variables were analysed: ICU stay, ICU outcome, presence or absence of Candida spp. multifocality, presence of positive skin tests and results of LTT stimulated with PHA. Data were analysed using the SPSS statistical program. Categorical variables were compared among groups with Chi-square or Fisher exact test as appropriate. Continuous variables were analysed with the Student’s t or Mann-Whitney U test when the distributions departed from normality and described as mean or median (standard deviation or variance). Statistical significance was established at p value < 0.05 on two-tailed testing. For statistical analysis, patients were grouped according to mortality (D: dead/S: survivors) or the presence of positive skin tests (P: positive/N: negative).

Results

No significant differences were detected between the number of days spent in the ICU and mortality (42% mortality in stays of less than 13 days vs. 48% in stays of more than 12 days, X2 = 0.16). Significant differences were detected between patients according to whether or not they had positive skin tests and mortality (mortality of 27.8% in patients with positive skin tests vs. 78.3% with negative skin tests, X2 = 10.45 (p = 0.001)) and between presence of multifocal candidiasis and mortality (30% mortality in patients with colonization vs. 73.9% in patients with multifocality, X2 = 8.29 (p = 0.004)). These differences are more significant if only the group with stays longer than 12 days is analysed (10% mortality in patients with colonization vs. 71.4% in patients with multifocalities, X2 = 10.24 (p = 0.001)). There were no significant differences between positive skin tests and the presence of Multifocal Candidiasis (50% of patients with colonization had negative skin tests vs. 60.9% of patients with multifocality, X2 = 0.48).

Related on the LTT PHA done:

  1. There are significant statistical differences between the control group and the study group, in relation to mortality (LTT PHA control group (group C) = 39.25% (6.79), LTT PHA study group survivors (group S) = 29.22% (11.67), LTT PHA study group dead (group D) = 22.89% (13.11). Statistical differences between group C and group S: t = 3.86 (65 d.f.), p = 4×10-4; between group C and group D: t = 6.29 (65 d.f.), p =6×10-8; between group S and group D: t = 2.45 (66 d.f.), p = 0.002). Statistically significant differences are not found when comparing the results of the LTT PHA of the first determination between group S and group D (LTT PHA group S = 27.29% (10.15), LTT PHA group D = 22.68% (12.33), t = 1.49 (34 d.f.), p = 0.131).
  2. There were significant statistical differences between the control group and the study groups, whether the skin tests were positive or negative (LTT PHA control group (group C) = 39, 25% (6.79), LTT PHA study group with positive skin tests (group P) = 30.03% (12.16), LTT PHA study group with negative skin tests (group N) = 21.52% (12.41). Statistical differences between group C and group P: t = 3.8 (66 d.f.), p = 0.001; between group C and group N: t = 6.98 (60 d.f.), p = 5×10-9; between group P and group N: t = 3.39 (62 d.f.), p = 0.002). There were significant statistical differences when comparing the results of LTT PHA of 2nd determination between group P and group N (LTT PHA group P = 30, 07% (10.73) and LTT PHA group N = 19,28% (10,59), t = 2,13 (18 d.f.), p = 0.025). Statistically significant differences are not found when comparing the results of the LTT PHA of the 1st determination between group P and group N (LTT PHA group P = 29.68% (8.27) and LTT PHA group N = 22.53% (13.05), t = 1.5 (34 d.f.), p = 0.129).
  3. When analysing the subgroup of patients with ICU stay of more than 12 days, there were significant statistical differences between the control group and the study group according to survivors with colonization (1st study LTT PHA: t = 3,8 (39 d.f.), p = 0,001; 2nd study LTT PHA: t = 3,461 (35 d.f.), p = 0.002) and dead with multifocality for Candida spp (1st study LTT PHA: t = 5,82 (41 d.f.), p = 1,3×10-6; 2nd study LTT PHA: t = 6,09 (43 d.f.), p = 4,5×10-7). There were only significant statistical differences between the control group and the study group according to survivors with multifocality for Candida spp in the 1st study LTT PHA (1st study LTT PHA: t = 3,957 (37 d.f.), p = 0,0005; 2nd study LTT PHA: t = 0,603 (35 d.f.), p = 0,329). There were only significant statistical differences between dead with multifocality for Candida spp. and survivors with multifocality for Candida spp. in the 2nd study LTT PHA (1st study LTT PHA: t = 0,751 (14 d.f.), p = 0,291; 2nd study LTT PHA: t = 3,764 (14 d.f.), p = 0.002) (Table 1). There were no deaths in patients with candida colonization of more than 12 days.

Table 1: LTT PHA results, 1st determination and 2nd determination, comparing control group with patients staying in the ICU for more than 12 days in the study group, collected according to mortality and presence or not of Multifocal Candidiasis.

Characteristics of the groups LTT PHA 1st determination

LTT PHA 2nd determination

Number of cases

Median Variance Number of tests Median

Variance

Control Group Healthy volunteers

33

39.25% 46 33 39.25% 46

Study Group with days of UCI stay > 12

Survivors and Candida spp colonization

8 27.69% 104.62 4 26.70%

30.99

Survivors and multifocal candidiasis

6

25.75% 111.35 4 37% 54.67

Dead and multifocal candidiasis

10 20.75% 166.17 12 20.78%

163.54

Discussion

Critical illness is defined by presence of altered organ function in acutely ill patients such that homeostasis cannot be maintained without medical intervention in ICU, such as mechanical ventilation, vasoactive support for hemodynamic, renal replacement therapy, and so on [7]. The Sequential Organ Failure Assessment (SOFA) score is a simple method of assessing and monitoring organ dysfunction in critically ill patients [8,9]. The prognostic value of skin tests in critically ill patients has been observed for years [10]. There is also evidence of the prognostic value of Multifocal Candidiasis in these non- neutropenic critically ill patients. The detection of Multifocal or Invasive Candidiasis [2] can be an indicator of acquired immunosuppression in ICU patients affected by a Multiple Organ Dysfunction Syndrome [10]. In the patients of the study, the need for mechanical ventilation for more than 24 h. together with continuous sedation, before identifying Multifocal Candidiasis, indicates that their SOFA score is higher than 5. This fact confirms that the selected patients are admitted to the ICU with a Multiple Organ Dysfunction Syndrome. The LTT PHA carried out in this study demonstrate that the cellular immunity of non- neutropenic patients requiring mechanical ventilation for more than 48 h. presented significantly lower values than in a control group of non-neutropenic subjects. These results confirm the existence of an immunological response known as endogenous immunosuppression [11] in non-neutropenic critically ill patients. At the same time, these statistically significant differences disappear in the 2nd determination of the LTT PHA in critically ill patients with an ICU stay of more than 12 days and who survive. Therefore, improvement of this T-cell dysregulation [12] will condition ICU outcome in patients who remain in critical condition for more than 12 days. This observation raises the possibility that quantitative and qualitative kinetic monitoring of T-lymphocytes in ICU patients may help to identify those who may benefit from new immunomodulatory therapeutic strategies [13]. A possibility of this monitoring can be found following the proposal of the REALIST score [14].

Conclusions

Both in vivo cellular immunity studies, using skin tests, and in vitro studies with the LTT PHA help to establish a prognosis in critically ill patients requiring long-term ICU care and in which a Multifocal Candidiasis has been identified. Monitoring of T-cell dysregulation and endogenous immunosuppression can help to identify patients who may benefit from new immunomodulatory therapeutic strategies.

Aknowledgements

Thank you to Torres Rodriguez JM. MD PhD, who served as scientific advisor.

References

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  2. Ibañez-Nolla J, Nolla-Salas M (2024) Multifocal Candidiasis can be considered a form of Invasive Candidiasis in critically non neutropenic patients. IJID 147: 107171.
  3. Monto Ho (1981) Non-bacterial infections in the Critical Care State of the Art (vol 2). Ed Shoemcker, UC y Thompson WL. Fullerton. California 1-12.
  4. Sprague JL, Kasper L, Hube B (2022) From intestinal colonization to systemic infections: Candida albicans translocation and Gut Microbes 14:2154548.
  5. Patterson L, McMullan R, Harrison DA (2019) Individual risk factors and critical care unit effects on Invasive Candida Infection occurring in critical care units in the UK: A multilevel Mycoses 62: 790-795.
  6. Surbatovic M, Vojvodic D, Khan W (2018) Immune response in critically ill patients. Mediators inflammation 2018: 9524315.
  7. Moreno R, Rhodes A, Piquilloud L, Hernandez G, Takala J, et al. (2023) The Sequential Organ Failure Assessment (SOFA) Score: has the time come for an Update? Critical Care 27: 15.
  8. Nolla M, León MA, Ibáñez J, Díaz RM, Merten A, et (1998) Sepsis-related organ failure assessment and withholding or withdrawing life support from critically ill patients. Critical Care 2: 61.
  9. George C, Robin M, Carlet J, Rapin R, Landais C, et al. (1978) Cellular immunity skin testing and sepsis in intensive care patients: relationship between results and Nouv Presse Med 7: 2541-2544.
  10. León Regidor MA, Ayuso Gatell A, Díaz Boladeras R, Robusté Morell J, Soria Guerrero G, et al. (1993) Candidiasis in an intensive care unit. Rev Clin Esp 193:49-54.
  11. Munford RS, Pugin J (2001) Normal responses to injury prevent systemic inflammation and can be Am J Respir Crit Care Med 163: 316- 321.
  12. Luperto M, Zafrani L (2022) T-cell dysregulation in inflammatory diseases in Intensive Care Medicine Experimental 10: 43.
  13. Rol ML, Venet F, Rimmele T, Moucadel V, Cortez P, et (2017) Rheanimation Low Immune Status Markers (REALISM) project: A protocol for broad characterisation and follow-up of injury-induced immunosuppression in intensive care unit (ICU) critically ill patients. BMJ Open 7: e015734.
  14. Tremblay JA, Peron F, Kreitmann L, Textoris J, Brengel-Pesce K, et al. (2022) A stratification strategy to predict secondary infection in critical illness-induced immune dysfunction: the REALIST Ann Intensive Care 12: 76.

Assessing the Effectiveness of Financial Management Technical Assistance to Immunization Programs:A Case Study on the Use of Mobile Money Payment Mechanisms in the Expanded Program on Immunization (EPI) Liberia

DOI: 10.31038/IJNM.2024562

 
 

The availability and adoption of mobile money services have transformed financial inclusion and service delivery in many developing countries (Donovan, 2012). In Liberia, the immunization program post Ebola Virus Disease (EVD) has faced challenges in efficiently managing financial resources and making timely payments to vaccinators and other health workers, thereby hindering the effectiveness of immunization service delivery. Hence, this mixed- method study was conducted in November 2024 to assess the impact of integrating mobile money payment mechanisms into the financial management system of the Expanded Program on Immunization in Liberia. The review of existing literature suggests that mobile money has the potential to enhance financial inclusion and improve the efficiency of immunization service delivery and other health services in the health sector. Mobile money has been shown to facilitate risk-sharing and promote welfare, though the evidence on its direct economic impact is still limited. (Aron, 2018) The use of mobile money for immunization programs specifically has shown promising results in increasing vaccination coverage through SMS reminders and educational tools for health workers. (Oliver‐Williams et al., 2017). In the case of Liberia, the integration of mobile money into the immunization program’s financial management modalities has helped address the challenges of timely payments and better assurance that payments reach persons for which they are intended, thereby improving health worker motivation and the overall effectiveness of the program. Liberia is dealing with the aftermath of brutal civil wars, the last of which ended in 2003. The infrastructure challenges include poor road infrastructure and underfunded health sector. Gavi, the vaccine alliance is the main funder for routine immunization in the Liberia. An review by the funder’s auditors in 2018 recommended improvements in the financial management systems for the grants at the Ministry of Health. The actions put in place included assurances that payments that MOH/EPI made at community level reached their targeted beficiaries, with timely submission of accountability reports to the center in Monrovia. In 2019, in response to severe economic constraints, the government implemented a salary harmonization exercise which included a cap on personnel recruitments. Subsequently, the development partners provide funding for monthly stipends for recruited health workers.

Highlights from Liberia’s Routine Immunization Program

Despite being one of the world’s least developed countries with low health sector funding, having a health expenditure per capita of $112 in 2021, Liberia immunization coverage for DTP 3 / Penta 3 is 82% (WUENIC 2023 Report) of its targeted population between the ages of 0-23 months by December 2023, from 78% in 2022 thereby recording a percentage increase of 4%. The country relies on the support of international organizations like GAVI, The Vaccine Alliance, USAID, The World Bank, WHO and UNICEF to undertake activities which assure a high immunization coverage. The COVID-19 pandemic affected immunization seeking behaviours because of fear, hesitancy, and mistrust about vaccines, which resulted in a drop in immunization coverage rates for routine vaccines. However, the government of Liberia and its partners were strategic in making a substantial comeback through the development and implementation of an immunization recovery plan, which culminated in increased immunization coverage, as evidenced by the WUENIC 2023 report. It can be recorded that the use of a mobile money payment mechanism for timely and transparent payment of fit-for-purpose immunization workforce (vaccinators and other health workers) was one of the enablers for Liberia’s success in the attainment of 81% fully vaccinated coverage for COVID-19 vaccine. Based on the progress made in increasing the immunization coverage as measured by DTP3 and MCV1, Liberia has been consistent over the past two years with attaining the Millennium Challenge Corporation (MCC) indicator for immunization thereby setting the government on track for obtaining a new MCC Compact.

Trend in Routine Immunization Coverage Despite Low Spending

By 2023, Liberia achieved a notable increase in vaccination coverage. For instance, according to the WUENIC report, the DPT3 vaccine coverage will rise from 65% in 2020 to 82% by 2023. This improvement was largely due to intensified and targeted vaccination efforts (i.e., Outreach, Periodic Intensification of Routine Immunization-PIRI campaigns, etc.), timely payments of remunerations, supportive supervision and the strengthening of the immunization program and, by extension, the health system. Despite these gains, challenges remain, including reaching zero-dose children in remote and underserved areas and maintaining consistent vaccine supply chains. Continued efforts and support from global health partners will be crucial to sustain and further improve immunization coverage in Liberia (Figure 1).

Figure 1: Efforts and support from global health partners.

A Key Lesson on the Use of Mobile Money Payment Mechanism in Enhancing Transparency, Accountability, and Improving Program Performance within the Liberia Expanded Program on Immunization

Mobile money has significantly transformed financial transactions of the Expanded Program on Immunization at the Ministry of Health, Republic of Liberia since its introduction in 2021. The Expanded Program on Immunization entered into contract with the two main mobile telecommunications services providers, MTN Lonestar and Orange. With the contracts, the mobile providers set up payment platforms at the Ministry of Health Office of Finance Management (OFM) and trained users. The EPI and OFM teams conducted a nationwide registration of vaccinators and their particulars including, health facilities assigned, county, names, phone number, and supervisor names. With this information, a payee master list was created and submitted to the mobile providers who validated the names and phone number. With this validated list, the Ministry of Health was able to make periodic payments to health workers. Liberia’s implementation of mobile money and significant advancements in routine vaccination coverage rates exemplify the impact of innovative digital solutions in enhancing the speed and efficiency of financial transactions, as well as in developing customized strategies for expanding coverage and addressing outbreaks of vaccine-preventable diseases. This situation illustrates the substantial outcomes that can be achieved through appropriate innovation and tailored strategies, even in constrained fiscal conditions. The accomplishments of Liberia’s Expanded Program on Immunization can be distilled into seven essential lessons.

National and Subnational Leadership

Based on one of the findings from Gavi’s Audit and Investigation in 2018, Gavi contracted a financial management firm to provide technical support and capacity building to the Expanded Program on Immunization and the Office of Financial Management (OFM). Said recommendation was embraced by the honorable minister and the senior management team of the ministry of health which play a crucial role in the effective implementation of mobile money for immunization programs in Liberia. At the national level, the honourable minister of health, the senior management team of the ministry, the EPI manager, the Office of Financial Management, the internal audit unit, and the compliance unit play pivotal roles in creating policy frameworks that facilitate the adoption and use of mobile money systems by the Expanded Program on Immunization (EPI) and other programs subsequently. This includes providing regulatory support and ensuring that the mobile money payment is secure and accessible to all immunization service providers (e.g., vaccinators and other health workers). For instance, a mobile money steering committee was established and headed by the honourable deputy minister for administration. By promoting public-private partnerships, national leaders encourage investment in mobile money infrastructure and ensure that the technology reaches even the most remote areas, thereby ensuring that other projects and programs adopt said payment mechanisms. At the sub-national level, county health officers, officers-in-charge, and community structures were essential in bridging the gap between national policies and community practices. At the community and health facilities levels, the community development committee and the health facility development committee were charged with the responsibility during their monthly sitting to leverage their close ties with community members in advocating and explaining the use of mobile money in health services, including immunization programs. Working directly with health workers and subnational leaders has helped in the effective implementation of mobile money systems that align with the specific needs and contexts of health facilities and their communities. Moreover, the collaboration between national and subnational leadership is crucial to enhancing the overall effectiveness of mobile money in immunization programs. National leaders can provide the necessary resources and policy support, while subnational leaders ensure that these policies are effectively implemented on the ground. By fostering a coordinated approach, leaders at all levels can address challenges such as technological literacy, network connectivity, and financial inclusion. Strong leadership ensures that the benefits of mobile money are maximized, leading to improved vaccination coverage rates and better health outcomes for the population. A key lesson learned is that strong leadership at the national and sub-national levels through collaborative effort is essential in transforming health service delivery, including immunization, and achieving broader public health goals in Liberia. The successful implementation of mobile money payments within the Expanded Program on Immunization is a glaring demonstration.

Vaccinators’ Satisfaction with Mobile Money Payment

Bringing payment directly to the payees is a transformative digital solution that has been a game changer within the immunization landscape because of its availability and the reduction of bureaucratic bottlenecks and logistics. Out of 252 fit-for-purpose vaccinators interviewed from 252 health facilities across nine counties from northwest, north-central, south-central, and south-eastern Liberia, 63.1% (n=159) said that they were satisfied with the use of the mobile money for immunization transaction which demonstrates increased financial inclusion, especially for those who previously had limited access to traditional banking services due to geographical location and struggle to receive their just remuneration after conducting immunization services. Additionally, they indicated that it has brought a sense of respect and dignity to them within their communities. Table one provides a detailed breakdown of respondents’ reactions to the use of mobile money payment mechanisms for immunization operations. Several key lessons have been learned from mobile money platform use as an innovation in financial management, particularly in Liberia. These lessons include but are not limited to the following (Table 1):

  • Challenges associated with traditional banking: The issue of limited banking facilities and long distances due to its geographical location has been eliminated.
  • Improve access and convenience: Immunization services have been significantly enhanced, thereby eliminating the need for physical cash transactions and reducing logistical barriers for vaccinators and other health workers working in remote and underserved areas due to the absence of bank access and direct access to cash on the mobile phone.
  • Enhanced transparency and accountability in the financial aspects of the immunization program through the provision of digital records for all financial transactions.
  • Strengthening trust and engagement between the vaccinators and the This ensures the continuous access and utilization of immunization services by the communities, which is crucial to improving immunization coverage and the larger public health goal of Liberia.

Table 1: How satisfied are you with receiving your payments through mobile money?

Frequency Per cent

Valid Percent

 

 

Valid

Very satisfied

89

35.3 35.3

Satisfied

159 63.1

63.1

Neutral

4

1.6 1.6

Total

252 100.0

100.0

Transactional Time: How Long Does it Usually Take for Vaccinators to Receive Payment after the Outreach Vaccination Campaign?

Payment of vaccinators for an outreach and/or vaccination campaign can vary widely based on several factors. Ideally, a well- structured mobile money system should be able to effect payment within 24 to 48 hours after the conduct of a health facility outreach and/ or vaccination campaign has ended. However, out of 252 vaccinators interviewed, 54.4% (n=137) stated that they received payments for health facilities outreach within one to two days upon completion. At the same time, 45.6% (n=115) indicated that it takes more than five days. A key lesson learned is that the system is effective to an extent because more than fifty per cent of the participants attest to receiving their payment within one to two days. However, it is noteworthy that there are some situations in which payment may not come so quickly. For instance, administrative inefficiencies, verification processes, loss of network and/or technical issues related to the mobile money platform can further delay the payment period. In some instances, delays for vaccinators might last for days or even weeks to receive the requirements for payment due. Indefinite delays could lead to considerable inconvenience and dissatisfaction among vaccinators, which will negatively impact their morale and the effectiveness of the program. Hence, having a well-structured system for resolving issues in a timely manner will also help to enhance mobile money payments’ reliability and efficiency for this fit-for-purpose immunization workforce and other health workers.

What is Your Overall Experience with Mobile Money Payments Compared to Traditional Payment Methods for Vaccinators?

The use of mobile money platforms as cashless payments has greatly improved the payment process for vaccinators when compared to the traditional system (e.g., hauling cash around) as payments are sent directly to their mobile phones, vaccinators no longer must spend long hours travelling to collect their salary. Out of 252 vaccinators interviewed about their experience with the use of mobile money platforms compared to the traditional system, 59.9% (n=151) indicated that they had a better experience with the use of mobile money as opposed to the traditional system, citing bureaucratic bottlenecks and logistics as major challenges associated with the traditional system as shown in table 2. It was highlighted that mobile money saves time and minimizes the risk involved with transporting cash. Finally, the instantaneous nature of mobile money transactions means that vaccinators are paid quickly, boosting their finances and morale in an immediate fashion. That said, mobile money payments come with their challenges. However, remote areas may experience network issues that could result in delayed transactions, while some vaccinators may not be digitally inclined and thus could face challenges in using mobile money platforms. While mobile money is deemed efficient, some vaccinators expressed concern about abuse and/or other lingering concerns, as the threat of fraud or unauthorized access to accounts is ever-present. Nonetheless, mobile money has generally been a positive change, providing both greater efficiency and greater access over traditional banking and cash-based systems (Table 2).

Table 2: What is the overall experience with mobile money payments compared to traditional payment methods for vaccinators?

 

Frequency

Per cent Valid Percent
 

 

 

Valid

Much better

70 27.8

27.8

Better

151

59.9 59.9

About the same

26 10.3

10.3

Worse

5

2.0 2.0

Total

252 100.0

100.0

How Would You Rate Challenges Associated with Accessing Payments through Mobile Money Platforms for Immunization Activities?

Out of 252 vaccinators interviewed, the majority (48%, n=121) indicated that accessing mobile money is easy when compared to the traditional system because their incentives and/or salary are paid directly on their mobile phone, meaning that they (e.g., vaccinators) no longer need to journey long distances to collect their wages. This payment method has enhanced the time spent on financial transactions while minimizing the risk of carrying cash. The real- time characteristic of mobile money payments is that vaccinators receive their payments immediately, allowing them greater financial stability – and, with that, motivation. However, there are still issues being faced when using mobile money payments. For instance, network challenges are one of the key challenges highlighted by vaccinators working in rural and underserved areas. Transforming immunization financial landscape using mobile money platforms, however, has been a journey that while positive overall, has not been without some bumps along the way, such as sub-optimal network coverage, therefore it is imperative to have a cross-sectoral approach to improving telecommunications access and digitial payments in the more remote areas of the country (Figure 2).

Figure 2: Cross-sectoral approach to improving telecommunications access and digitial payments in the more remote areas of the country.

Leveraging Data, Tracking Performance and Payments, and Course Correction

To ensure efficient immunization spending, data-driven strategies like health facility microplanning, mobile money payment reconciliation, and community profiling have been essential in identifying, monitoring, and improving vaccination efforts. By mapping and profiling communities, the immunization program can develop tailored service delivery interventions to reach zero-dose children, missed children, and underserved communities. This targeted approach allows districts and counties to use health microplanning to pinpoint areas with low vaccination coverage rates effectively. By doing so, their efforts were concentrated on specific areas, enabling them to apply targeted interventions and adjust strategies in real- time. The use of data ensured that no community was overlooked and that corrective measures were both timely and effective. A key lesson learned is that understanding the target population and their locations is crucial to achieving successful immunization outcomes.

Hence, it is imperative to underscore the need for high-quality data to implement targeted interventions effectively. Therefore, investing in data quality is therefore critical for both routine immunization programs, financial decisions, and outbreak response efforts.

Immunization Supply Chain and Logistics Management Information System

In Liberia, the use of mobile money services has significantly enhanced communication on the immunization supply chain and logistics management information system by ensuring the conduct of monthly health facilities outreach and averting potential and/or reducing stockouts of vaccines and vaccine supplies. 70% (n=176) of respondents indicated that with the timely payment of outreach support and monthly incentives, they could transport their vaccines to avoid stockouts and maintain the health facility’s integrity with the communities. A key lesson learned is the importance of local leadership at the health facility level to avert stockouts of vaccines and supplies, especially in hard-to-reach areas, where delivering multiple vaccines is challenging due to geographical accessibility.

Association Between Outreach Payment and Increased DTP3/Penta3 Immunization Coverage

A study was conducted to determine the association between outreach payment and increased DTP3 / Penta3 immunization coverage. Out of 252 vaccinators interviewed, a chi-square test analysis was run to determine the likelihood of an association. However, the findings revealed that a value of 0.282 with 1 degree of freedom (df) and an asymptotic significance (p-value) of 0.595 were observed. This indicates that the observed data are not significantly different from what would be expected under the null hypothesis. Hence, the observed data reveals that there is no association between outreach payment and an increase in DTP3/ Penta 3 coverage (Table 3).

Table 3: Chi-Square Tests

 

Value

df Asymptotic Significance (2-sided) Exact Sig. (2-sided)

Exact Sig. (1-sided)

Pearson Chi-Square

.282a

1 .595    

Continuity Correction

.141 1

.708

   
Likelihood Ratio

.286

1 .593    

Fisher’s Exact Test

      .642

.357

Linear-by-Linear Association

.281

1

.596

   
N of Valid Cases

252

       

Contribution to the Eruption Mechanism of Carbonatitic Diatremes and Volcanoes

DOI: 10.31038/GEMS.2024673

Abstract

The Eifel Volcanic Field (EVC) is one of the best-known intraplate volcanic fields on earth. Carbonatitic ejecta were already described at the beginning of the last century and were associated with volcanism. The investigation of carbonatitic tephra from the EVC, the Kaiserstuhl (KVC) and El Hierro (EHSR) with regard to shape, size, composition and geochemistry, together with thermodynamic and fluid mechanical considerations, allow a reconstruction of the eruption process that ultimately calls into question the sole interpretation of maar formation as a phraetomagmatic eruption.

Introduction

In their overview of the worldwide distribution of carbonatites, Woolley and Kjarsgaard (2008) [1] report 527 carbonatite localities, 46 of which are classified as extrusive. The ratio is unlikely to have changed significantly to date. While the intrusive carbonatites represent the frozen state of a relatively slow intruding melt that has cooled in the host rock, the extrusive carbonatites are the result of sudden events that, due to the physical nature of the carbonatite melts, leave behind mechanical but only minor chemical traces. The genesis of carbonatitic melts can be very different, depending on whether they occur alone or in combination with alkali silicate rocks. They can be formed primarily by partial melting in the mantle or also by fractional crystallization of melilitic-nephelinitic magmas or generally by segregation of silicate melts supersaturated with carbonate [2]. In all cases considered, the carbonatitic events are determined by the unique properties of the carbonatite melts themselves [2]. For example, carbonatites generally have a high solubility for rare earth elements, which makes them economically interesting. They have a strongly pressure-dependent density of 2000 kg /m3 at P = 0.1 GPa up to 2900 kg/m3 at P = 10 GPa, a very low viscosity and a high solubility of CO2 and H2O (Genge et al 1995). The high solubility of CO2 in carbonatitic melts is associated with the onset of incongruent melting of CaCO3 at temperatures > 1230°C and a pressure range of 0.1 – 0.7 GPa according to the reaction [3].

2CaCO3 (solid) = (CaCO3 +CaO)(liquid) + CO2                   Eq (1)

A further increase in pressure ultimately leads to congruent melting [3-4]. The incongruent melting behavior of CaCO3 explains the high saturation of carbonatite melts with CO2 . This saturation is associated with a drastic reduction in the melting temperature (solidification temperature). According to Huang and Wyllie (1976) [5], saturation of the carbonate melt with CO2 to 11.5 wt% at 2.7 GPa results in a melting point reduction from 1610°C to 1505°C. Investigations by Eggler (1974) [6] on the solubility of CO2 in diopside at 3 GPa show that mantle silicate melts dissolve approx. 5 wt% CO2 , which is associated with a melting point reduction of 120 degrees. Due to the incongruent melting behavior of the carbonate [Eq (1)], a high CO2 content of the melt combined with high fluidity and low density is inevitable. A high H2 O content also has the effect of lowering viscosity and melting point, which is particularly important in silicate melts. The low viscosity of carbonatitic melts leads to magma ascent velocities of 20 – 65 m/s (70-230 km/h) if the appropriate tectonic conditions are present [45]. However, this also means that extrusive carbonatitic events are unpredictable. Furthermore, rapid magma ascent leads to rapid depressurization, which results in spontaneous release of the CO2 dissolved in the melt and decomposition of the carbonate according to the relationship leads.

CaCO3 = CaO + CO 2               Eq (2)

This creates a gigantic CO2 fan at depths of 3 – 20 kilometers. This means that the probability of carbonatitic melt reaching the earth’s surface is very low. Such carbonatitic diatreme fillings are characterized by a quantitatively high proportion of accessory rock xenoliths, which can amount to 70% and more [7]. Silicate-magmatic tephra occurs when the eruptive reservoir is a carbonate-bearing silicate magma. Stoppa et al (2003) [8] have pointed out these processes. The type of eruption also means that only small traces of the carbonatite itself can be found. This may also be the reason why only a small number of extrusive carbonatites have been detected to date. A model is being developed from the known data of carbonatitic melts, which allows a better understanding of the phenomena associated with carbonatitic volcanism and a better interpretation of the material found in the field. For this purpose, data from sample material from three known volcanic fields are used: the Eifel (EVC = Eifel Volcanic Complex), the Kaiserstuhl KVC = Kaiserstuhl Volcanic Complex) and El Hierro (EHSR = El Hierro South Rift).

Geological Context of the Regions Belonging to the Sample Material

EVC, Eifel Volcanic Complex

One of the most famous intraplate volcanic districts in the world is located in the Eifel, as it contains the type locality of the Maar eruption type. The Eifel volcanic field has two quaternary volcanic fields that follow tectonic northwest-southeast AC fissures of the Variscan folded crust. The West Eifel consists of around 240 eruption centers, the East Eifel of around 100 [9]. Due to the economic use of the volcanic structures for the extraction of building materials, gravel and pumice, the two Eifel volcanic fields are excellently accessible for geological investigations. Multiphase volcanic activity began in both volcanic fields around 700 ka ago [10-11]. The last activities occurred in the Western Eifel around 11 ka ago with the eruption of the Ulmen Maar [12] and in the Eastern Eifel around 13 ka ago with the eruption of the Laacher See Volcano [13]. Two older foidite suites (melilitite, melilitite-nephelinite and ol-nephelinite/leucitite and leucite- phonolite) and a younger basanite-tephrite-phonolite suite [14-16] occur in both volcanic fields. In the West Eifel, the basanite suite first appears around 80 ka, in the East Eifel at around 215 ka [10-11]. These alkali-rich magmas originate from varying degrees of partial melting in the upper mantle (< 120 km), which were subjected to more or less strong differentiation by fractional crystallization on their way to the Earth’s surface. The foiditic magmas in particular are potential sources of carbonate-bearing to carbonatitic magmatic rocks, which have long been known from the Laacher See region [17-19]. They were first described from the West Eifel by Lloyd and Bailey (1969) – [20] and again investigated by Riley et al. (1996) [21] and Riley et al. (1999) [22]. To date, however, scientific interest in the Eifel carbonatites has remained rather low. A dissertation on the genesis of the Laacher See carbonatites was published by Liebsch (1997) – [23]. He interpreted the Laacher See carbonatites as precipitates from a phonolitic silicate melt supersaturated with carbonate in the last stage of differentiation and cooling. This work is little known as its results have not been published. Schmidt et al. (2010) [24] investigated the temporal development of intrusive carbonatites using uranium-thorium dating on the same sample material. Since 2019, an international working group led by the German Volcanological Society has turned its attention to the problem of Eifel carbonatites. The initial focus is on a geological survey combined with the discovery of further carbonatite deposits.

The carbonatite deposit of the Laacher See volcano is the youngest in the Eifel with an age of 13 ka years. The other known carbonatite deposits in the Eifel are located in the Rieden complex (Eastern Eifel) [25] and in the Western Eifel in the Rockeskyll and Essinger Maar area. They are generally linked to phonolitic magmatism and are characterized by the associated occurrence of sanidine megacrysts with masses of up to 60 kilograms. In terms of age, the West Eifel deposits can be dated to approx. 469 ka years ago and the East Eifel deposits to 410 ka years ago [10, 26]. If one takes the conspicuous association of sanidine megacrysts and carbonatites as an indicator, then there are still 3 carbonatite-rich areas. One area is the Kerpener- Maar in the West Eifel. This is a phonolitic maar, which is also known for its sanidine megacrysts [14]. The other two deposits are located in the Eastern Eifel. One is located on the southern edge of the Wehrer Kessel, a polyphase phonolitic eruption center where, according to Frechen (1976) [27], sanidine megacrysts were also found in the Wehr I tephra. The age of the deposits of the Wehr I eruption is given by Wörner et al. (1988) [28] as 480 ka years. The other occurrence is in the area of the Leilenkopf near Niederlützingen, where the oldest melilitic-nephelinitic deposits of the Leilenkopf volcano are also said to contain sanidine megacrysts [29]. The age of these sanidine ejecta was determined to be 405 ka years [30]. However, all 3 of these carbonatite-rich deposits are currently unexplored.

KVC, Kaiserstuhl Volcanic Complex

The Kaiserstuhl Volcanic Complex is the best-studied carbonatite complex in Europe [31-34]. Its age is given as 16-19 Ma [35], Braunger [36]. It consists mainly of tephritic to phonolitic rocks, associated with a small proportion of olivine nephelinites and melilites. The youngest formations are the carbonatites, whose age is given as 15 Ma [33]. The magmatic origin of the carbonatites from the Kaiserstuhl was first postulated by Högbom in 1895 [33]. The carbonatites of the KVC occur both as subvolcanic carbonatite bodies of sövitic character and as extrusive events in the form of dykes, veins and carbonatitic tephra. Carbonatitic tephras are of particular importance for the investigation of the eruption mechanism of carbonatitic volcanoes. A special feature of the Kaiserstuhl ejecta are the lapillite tuffs known from Henkenberg and Kirchberg, which are only known from a few other localities (Cape Verde, Silva et al. 1981 [37], Fort Portal Volcanic Field, Uganda, Barker and Nixon 1988) [38]. They are so distinctive that they form the locus typicus for this type of tuff. Since this paper is concerned with the interpretation of the eruption mechanisms of carbonatitic volcanoes, only those samples that can be expected to contribute to this topic were considered in the processing.

Region El Hierro, South Rift (EHSR)

El Hierro is one of the seven volcanic islands of the Canary Islands archipelago, which is located approximately 100 kilometers northwest of Africa in the Atlantic Ocean. The age of the archipelago is estimated at around 60 million years, with the island of El Hierro being the youngest link in this chain at around 1.2 million years old. All islands are considered volcanically active [39]. El Hierro can be divided into 3 rift systems [40]. The North-East Rift (Tinor Volcano, 1.2-0.88 Ma), the West Rift (El Golfo Volcano, 0.55-0.176 Ma) and the South Rift (0.158 Ma – today). The South Rift is the youngest formation and had its last eruption in 2011 as a submarine volcano off the southern tip of the island. The South Rift volcanism is characterized by highly differentiated lavas of tephritic character. Such lavas originating from tephritic magmas are certainly indicative of carbonate-enriched silicate rocks and their differentiates (carbonatites). The search for carbonatitic ejecta is therefore quite promising and opens up the possibility of verifying the thesis of the dissociation of CaCO3 with subsequent recombination according to equations 2 to 5 by applying the C14 determination method. Since C14 is only formed under the influence of high-energy particles in the atmosphere, volcanic CO2 is ad hoc free of C14 . If the detection of C14 in carbonatitic tephra is successful, then the proof for the sequence of reactions according to equations 2 to 5 is provided. As the isotope C14 is a relatively short- lived nuclide with a half-life of 5730 years, verification must take place in a young volcanic area with carbonatitic episodes. Through a systematic search, the author found suitable sample material for a C14 determination in the South Rift of El Hierro.

Gas Mechanical Processes in the Light of Volcanology

Depending on pressure, flow velocity, flow type, solid and liquid content, a gas flow through a tube produces effects that have long been used in technology and that can be studied excellently on extrusive carbonatites from the Eifel. Some of the gas-mechanical processes that we will deal with below are known as fluidized bed processes. In volcanology, publications dealing with this topic appear from time to time [41-44].

Basically, three processes can be distinguished in the fluidized bed process, depending on the prevailing conditions:

  1. Agglomeration, granulation, integration
  2. Abrasion, disintegration, fragmentation
  3. Transportation

The result of all three modes can be demonstrated on diatremes in the Eifel.

We want to understand a diatreme sensu stricto as a volcanic ascent channel, which is very narrow in relation to its length and can reach the Earth’s mantle under certain circumstances. It is tectonically pre-formed and is created by mechanical fragmentation as a result of rapidly rising highly fluid melts (70-230km/h; Genge et al 1995) [45]. In the case of carbonate-containing melts, these reach a pressure level during ascent at which the decomposition reaction of the calcium carbonate according to Eq. (1) and Eq. (2) begins explosively, which is accompanied by a fragmentation of the residual channel up to the earth’s surface. This leads to foreign xenolith contents of up to 70% and more in the eruption centers. The explosive initial phase can be followed by a quieter degassing phase, which can be described by a kind of boiling reaction in a relatively narrowly defined area of the ascent zone, whereby this area can be characterized by the diameter of the diatreme and the thickness of the boiling zone. The intensity of the eruption is determined by the amount of material extracted from the depth per unit of time. The onset of the reactions according to equations (1) and (2) is associated with the emission of large quantities of CaO in the volcanic ejecta. This fact has not yet been mentioned in the literature, although one has to ask how carbonatitic tuff was formed. Obviously, it is tacitly assumed that a carbonate liquid phase cemented the tephra particles. However, we have no known C, O and Sr isotope data to prove that the binding phase of the tephra is magmatic in nature (according to the usual criteria for magmatic isotopy, Taylor et al. 1967) [46]. As a way out of this dilemma, it is argued that the isotopy of the tephra has been altered by alteration processes (Demeny et al 1998) [47].

Accordingly, large quantities of CaO and CO2 are released into the atmosphere during the eruption. The overall isotopic picture of the CaCO3 is therefore split into a CaO isotope and a CO2 isotope. Both components are carried into the atmosphere, where they are influenced by the prevailing conditions such as humidity, temperature and air velocity. While the CO2 remains as a gas, the CaO sinks back to the earth’s surface as dust. The CaO can recombine with volcanic CO2 or CO2 from the air or react with the moisture in the air. The following reactions are possible:

CaO + CO2 = CaCO3                                   Eq (3)

CaO + H2 O = Ca(OH)2                              Eq (4)

Ca(OH)2 + CO2 = CaCO3 + H O2             Eq (5)

There is therefore ultimately a fallout of clasts (predominantly xenoliths from secondary rocks, but also xenocryst fragments from the primary carbonate melt) and a dust mixture of CaO, Ca(OH)2 and CaCO3 , with CaO as the main component. This dust forms the binding material for the carbonatitic tuff, whereby CaO and Ca(OH)2 are transformed into CaCO3 by the atmospherics according to Eqs. (4) and (5), a process that also takes place with quicklime. Ultimately, a tuff with a carbonate binder phase is formed. We will return to these facts below (Figure 1a-1c).

Figure 1a-c: Tuff with carbonate binder phase.

Above the evaporation zone, turbulence can occur within the ascent channel if the appropriate conditions for flow velocity and pressure are present, leading to the formation of a fluidized bed. This means that the diatreme is in agglomeration or granulation mode. Depending on the role played by the liquid phase involved, we obtain accretionary lapilli or droplet lapilli. Accretionary lapilli are formed when dust particles collect in a rotating gas flow and stick together due to a highly fluid medium (carbonatite melt). Droplet lapilli are formed when low-viscosity silicate melt (e.g. melilititic or melilite- nephelinitic) is atomized and the droplets agglomerate in the turbulent gas space. This causes the so-called “cauliflower surface” of these lapilli (Figure 2a-2b).

Figure 2:

The lapilli can occur with or without a nucleation center, with the droplet lapilli often forming around an inclusions or juxtaposed xenolith (Figure 2c-2d) with and without nucleation center (micrograph, edge length approx. 2.5 cm). If the flow conditions in the ascending channel change, the system can switch from agglomeration mode to abrasion mode. In this case, the rotating clasts transported in the conveyor chute are rounded in a similar way to a sandblasting fan. The rounded sanidine megacrysts from Rockeskyll and Hohenfels- Essingen, whose rounded surfaces have so far been interpreted as fusions, are well known (Eilhard 2018) [48]. There are also plenty of rounded accessory rock xenoliths and comagmatic clasts in the form of pyroxenites and amphibolites (Figure 3a-3b).

Figure 3:

The Problem of the Carbonatitic Binding Phase in Tephra

Ultimately, the problem of CO2 emission in carbonatitic volcanic eruptions can only be solved according to equation 2 by analyzing the binding phase of carbonatitic tephra. For this reason, we will deal with carbonatitic tephra from various volcanic regions in the following. These volcanic areas are the Eifel (EVC = Eifel Volcanic Complex), the Kaiserstuhl (KVC = Kaiserstuhl Volcanic Complex) and El Hierro (EHSR = El Hierro South Rift).

Sample Material from the EVC

The sample material comes from both the Eastern Eifel (EEVC) and the Western Eifel (WEVC).

In detail, the samples are as follows:

68.3 Tephra, EEVC, Thürer Wald

101.5 subvolcanic soevite, EEVC, Thürer Wald

101.6 Sövite, carbonatitic vein, EEVC, Thürer Wald

94.1 Tephra, WEVC, Essinger Maar

94.5 Tephra, WEVC, Essinger Maar

94.6 Tephra, WEVC, Essinger Maar

95.1 Tephra WEVC, Pulvermaar

Material 101.5 and 101.6 are subvolcanic carbonatites. Figures 4a and 4b provide a visual impression.

Figure 4:

The isotope signature can be used as a starting point (Table 1):

These data are typical for magmatic carbonatites. We will find comparable data in the subvolcanic soevites of the Kaiserstuhl.

Table 1: Isotope signature.

 

δ44Ca

δ13C δ18O 87Sr/86Sr Sr/μg g-1
101.5 -6,12 7,52 0,70442

14990

101.6

-5,79 7,53 0,70439

15060

Description of the Sample Material

Tephra Thürer Wald, Sample 68.3

The volcanic clastics are cemented by a zeolitic-carbonatitic binding phase. As a result of a syneruptive or posteruptive hydrothermal phase. The geochemical data of the carbonatitic phase are listed in the following table (Table 2).

Table 2: Geochemical data of the carbonatitic phase.

δ44Ca

δ13C δ18O 87Sr/86Sr Sr/μg g-1
68.3 -7,54 21,68 0,70442

3500

The oxygen signature indicates that the fluid phase was under the influence of vadose waters, with the magmatic signature of carbon and Sr preserved.

Tephra Essinger Maar, Sample 94.1/5/6 and Tephra Pulvermaar, Sample 95.1

They show the volcanic clastics embedded in a carbonatitic binding phase, whose isotopic signature is shown in the following table (Table 3 and Figure 5a-5c).

Table 3: Volcanic clastics embedded in a carbonatitic binding phase.

 

δ44Ca

δ13C δ18O 87Sr/86Sr Sr/μg g-1

94.1

-17,94 19,47 0,70594 800
94.5 0,53 -13,32 22,18 0,70645

410

94.6

0,59 -20,35 19,51 0,70613

1900

95.1

-12,64 25,60 0,70603

1900

Figure 5: The tephra of the Essinger Maar is shown in a-c.

The direct indication of the magmatic origin of the Eifel tephra is provided by the high Sr content. The Sr content of sedimentary limestones of the Eifel is max. 300 ppm. The C and O isotopy of the carbonate tephra binding phase can no longer represent the Taylor criteria for magmatic isotopy [46] due to its origin. The strontium content of the carbonate binding phase was determined at the tephra of the three localities EM, PM and TW using the ICP-OES method. The tephra of the Pulvermaar is not yet diagenetically consolidated due to its young age. The CaCO3 appears as an outer coating on the tephra particles, as demonstrated in the Figure 6.

Figure 6: Tephra from the Pulvermaar.

The figure shows the state of the tephra of the Pulvermaar on the left and the state after treatment with diluted acetic acid on the right. The CaCO3 coating has been removed in this case. However, this means that the tephra particles were embedded in the dusty fallout of CaO, Ca(OH)2 and CaCO3 and not in a liquid binding phase of CaCO3 melt.

Sample Material from KVC

The material was collected in 2023 and then processed. In detail, the samples are as follows:

Sample.                             Remarks.

69.1.                                  subvolcanic sövite, Badloch

97.2                                   Droplet lapilli, Kirchberg

105.1.                                Droplet lapilli, Henkenberg

105.4                                 Droplet lapilli, Henkenberg

105.5                                  white tephra, Henkenberg

105.6                                  hydrothermal limestone, Henkenberg

105.9                                  gray tephra, Henkenberg

105.10                                gray tephra, Henkenberg

Sample 69.1 is the reference value for the initial magma with the following isotope ratios (Table 4):

Table 4: The reference value for the initial magma with isotope ratios.

δ44Ca

δ13C δ18O 87Sr/86Sr Sr/μg g-1
0,60- -6,05 7,08 0,70357

0,70357

Description of the Sample Material

Droplet lapilli from Kirchberg, 97.2.

Figures 7a and 7b provide a visual impression of the sample material. The scale in mm is indicated at the bottom of the images. Figure 7b clearly shows the spherical shape of the droplets (droplet), which indicates that they were deposited in a solid state.

Figure 7a and b: Droplet lapilli from Kirchberg.

The isotope data are as follows (Table 5):

Table 5: Isotope data.

δ44Ca

δ13C δ18O 87Sr/86Sr Sr/μg g-1
0,48 -7,92 15,53 0,70354

4690

Figures 8a, b and c show the BSE image and the Ca and Sr element distribution mapping of a droplet. The Sr- mapping shows very nicely large Ca primary crystals floating in a matrix of fine crystalline CaCO3, which can be interpreted as residual solidification.

A pronounced carbonatitic binding phase similar to that of the Thürer Wald sample material is not present. This is also confirmed by comparing the δ13C values of the whole rock (wr) and the isolated droplet, which are almost identical (see Hubberten 1988 [49] Hay and O’Neil 1983 [50] and table 10.

Droplet Lapilli vom Henkenberg, 105.1 and 105.4.

A striking feature of Figure 9a is the occurrence of light (Dl) and dark (Dd) droplets in the center of the image, embedded in a strongly developed carbonate phase (M). Detailed examinations of the microstructural components (see pictures) reveal the following picture (Table 6).

Table 6: Detailed examinations of the microstructural components.

 

δ44Ca

δ13C δ18O 87Sr/86Sr Sr/μg g-1

Dd dark

0,66 -7,91 14,66 0,70376

3450

Dl light

–9,43 15,67 0,70376 3450

Matrix

0,80 -11,57 24,6

<NWG

Figure 9: a, b and c provide an optical impression of the sample material. Figure c shows a micrograph.

The absence of strontium and the high δ18O value of 24.6 ‰, as well as the occurrence of drusen spaces with calcite crystals in the matrix (9b) indicate a hydrothermal post-phase with vadose waters, which also explains the partial alteration of the magnetites and the associated brown coloration of part of the droplets.

Siliceous tephra from Henkenberg, 105.9 and 105. 10.

Figure 10 gives an optical impression of the tephra. 84% of the material consists of CaCO3 . In addition, fragments of silicate minerals such as olivine, pyroxene, Al-Ca-Fe-containing garnet and Mg-Al-Ti- containing iron spinel occur.

Figure 10: 84% of the material consist of CaCO3. In addition fragments of silicate minerals such as olivin, pyroxene, Al-Ca-fe containing garnets and Mg-Al-Ti containing spinel occur.

The isotope data are as follows (Table 7):

Table 7: Isotope data.

Sample

δ44Ca

δ13C δ18O 87Sr/86Sr Sr/μg g-1
105.9 0,42 -10,02 24,02 0,70477

281

105.10

0,80 -10,26 23,95 0,70485

239

Remarkable is the occurrence of calcite crystal fragments, with strontium contents of approx. 3000 μg g-1, which are interpreted as ejected primary crystal fragments from the carbonatitic magma (Figure 11a-b, 12a-b, and 13a-c).

Figure 11: a and b shows an 800 µm x 450 µm primary crystal fragment in thin section. Figure a parallel polarizers, figure b crossed polarizers. It can be clearly seen that the calcite matrix has recrystallized at the edge of the primary crystal fragment. The grain size of this edge is up to 100 µm in contrast to the matrix, which has a grain size of approx. 15 µm. The same proportions can also be seen on the primary crystal fragments of garnet and spinel in Fig. 12 a and b.

Figure 12:

Figure 13: a, b and c show the BSE image and the Ca and Sr mappings of the calcite xenolith.

Silicate-free tephra from Henkenberg, 105.5.

The material consists of 99% CaCO3 . Figure 15 gives a visual impression of the sample material (Figure 14).

Figure 14: Silicate-free tephra.

The isotope data are as follows (Table 8):

Table 8: Isotope data.

Sample

δ44Ca

δ13C δ18O 87Sr/86Sr Sr/μg g-1
105.5 1,03 -9,82 24,42 0,70656

68

The thin section shows a uniform growth structure with grain sizes of 20µm to 50µm. No foreign mineral phases are recognizable (Figure 15).

Figure 15: Thin section of sample 105.5.

The results of samples 105.5, 105.9 and 105.10 can be easily explained if one assumes that CaO and CO2 are erupted during a carbonatitic volcanic eruption and that the reactions take place according to equations 2 to 5.

During the eruption, CaO dust is blown into the atmosphere, which gradually sediments again. Coarser particles, such as mineral fragments and calcite clasts, are also deposited near the eruption site, as can be seen in material 105.9 and 105.10. The heavy SrO is also deposited near the eruption site. The material of sample 105.5 was transported further, making it xenolith-free, as the heavy crystal fragments sediment near the eruption site. Similarly, the strontium content decreases with distance from the eruption site. The material from Badloch has a strontium content of 9300 μg g-1, material 105.9/10 has a strontium content of 280 μg g-1 and material 105.5 of 68 μg g-1. The xenolith crystals of samples 105.9/10 act as nucleation centers for carbonate formation, as can be clearly seen.

Sample Material from EHSR

The find situation can be seen in Figures 16 and 17.

The discovery points are approx. 3 kilometers apart.

Figure 16: Finding point sample 108.1.

Figure 17: Finding point samples 108.2 and 108.3

Description of the Sample Material

The geochemical data is shown in the table (Table 9 and Figure 18a-c). These three tephras are not yet strongly diagenetically consolidated. As a result, surface waters can exert a strong altering influence. Nevertheless, the tephras show a clear magmatic signature, the C and O isotope values are shifted in the sense of Hay and O’Neil towards carbonates in equilibrium with meteoric water [50]. The 14C isotope analysis has shown that a considerable 14C content is present, which correlates with ages of 9000 and 4000 years. These ages represent maximum values, as the dilution effect of the natural air CO2 content by the volcanic CO2 means that the initial value of 14C is lower than is normally assumed. In any case, the detection of 14C in the tephra confirms the sequence of reactions according to equations 2 to 5.

Table 9: Geochemical data.

sample

δ44Ca

δ13C δ18O  87Sr/86Sr Sr/μg g-1 14C
108.1 0,79 -7,71 28,55 0,70390 980

0,5497

108.2

0,91 -8,931 28,12 0,70373 1100 n.d.
108.3 1,41 -8,832 29,24 0,70464 494

0,3262

Figure 18: a to c provide an impression of the sample material.

Results and Discussion

It can be seen that the δ18O value of the carbonatitic binder phase is generally greater than 20 ‰. Obviously, the δ18O value of the carbonatitic source materials (CaO and CO2) changes under the influence of atmospheric oxygen (δ18O = 23.5 ‰) in the eruption cloud to these high values of δ18O > 20‰ (Table 10).

Table 10: Summarizes the results of the tephra data.

Sample

Location age/Ma Sr/μg g-1 δ13C δ18O 87Sr/86Sr δ44Ca
68.3 TW 0,44 3500_ic -7,54 21,68 0,70442

n.d.

94.1

EM 0,47 800_ic -17,94 19,47 0,70594 n.d.
94.5 EM 0,47 410_ic -13,32 22,18 0,70645

0,53

94.6

EM 0,47 1900_ic -20,35 19,51 0,70613 0,59
95.1 PM 0,03 1900_ic -12,64 25,6 0,70603

n.d.

105.5

KS/HB 16,4 68_ic -9,822 24,42 0,70656 1,03
105.9 KS/HB 16,4 281_ic -10,02 24,02 0,70477

0,42

105.10

KS/HB 16,4 238_ic -10,26 23,95 0,70458 0,8
97.2 KS/K 16,4 4690_wr -7,92 15,53 0,70354

0,48

105.1/GLD

KS/HB 16,4 3450 -7,91 14,66 0,70376 0,66
105.1/GLH KS/HB 16,4 3450 -9,43 15,67

0,70376

 

105.1/M

KS/HB 16,4 <NWG -11,57 24,6   0,8
wr KS/K 16,4 n.d. -7,6 16,9  

Data from [49]

wr

KS/K 16,4 n.d. -7,8 15,7   Data from [49]
isolated lapilli KS/K 16,4 n.d. -7,1 15,6  

Data from [49]

isolated lapilli

KS/HB 16,4 n.d. -8,8 15   Data from [49]
M KS/HB 16,4 n.d. -10,4 24,6  

Data from [49]

M

KS/HB 16,4 n.d. -10,2 24,7   Data from [49]
M KS/HB 16,4 n.d. -10,2 24,6  

Data from [49]

GL

KS/HB 16,4 3500 -9,3 13,9 Data from [50] Data from [50]
GL KS/HB 16,4 3500 -9,2 14,3 Data from [50]

Data from [50]

GL

KS/HB 16,4 3500 -8,4 14,7 Data from [50] Data from [50]
M KS/HB 16,4 <NWG -17,7 20,6 Data from [50]

Data from [50]

M

KS/HB 16,4 <NWG -12,1 23 Data from [50] Data from [50]
108.1 El_H 0,003 980_ic -7,71 28,55 0,70390

0,79

108.2

EL_H 0,003 1100_ic -8,931 28,12 0,70373 0,91
108.3 El_H 0,003 494_wr -8,832 29,24 0,70464

1,41

Ic: isolated carbonate, wr: whole rock, n.d.: not detected.

The δ13C value does not change during the eruption as it lacks the exchange partner and the small amount of CO2 in the air also has a δ13 C value of -6.5‰. This means that the change in the δ C value of the tuffitic binding phase is due to later alteration. This can be seen very clearly in the tephra of El Hierro, which can be regarded as recent at around 3 ta and which still fulfills the Taylor criterion for carbon with values of δ13C of around -8‰, while the oxygen is already far from this with values of 28 ‰. This shows that the C isotope ratio will be changed by alteration processes after the eruption. However, the lapilli tephra from Kaiserstuhl also shows that the isotopic composition δ13C of massive carbonatite, as present in the lapilli, is much more stable than the δ18O isotopy. The values in the table also show that in cases where the δ13C isotope does not deviate or deviates only slightly from the Taylor criterion, the 87Sr/86Sr value has a magmatic signature. The formation of the droplet lapilli at Kirchberg and Henkenberg must have taken place under conditions that are extremely rarely realized in nature. This shows that only three such sites are currently known: Kaiserstuhl [51], Cape Verde Islands [37] and Fort Portal Volcanic Field, Uganda (Barker and Nixon 1988 [38]). The carbonate melt must have spattered. It then formed into a sphere due to the surface tension and suddenly solidified. Accordingly, the micrographs Figure 8c show calcite primary crystals precipitated from the melt and a fine-grained matrix as residual solidification.

Figure 8: a, b and c show the BSE image and the Ca and Sr element distribution mapping of a droplet. The Sr- mapping shows very nicely large Ca primary crystals floating in a matrix of fine crystalline CaCO3 , which can be interpreted as residual solidification.

The synthesis of physical data on the pressure- and temperature- dependent phase relationships in the CaCO3 system and the findings on the dissolution behaviour of CaCO3 and H2O in silicate melts and their influence on the density and fluidity of the melts under consideration, as well as the calculation of the associated ascent rates, allow conclusions to be drawn about the eruption behaviour in diatremes. Diatremes are bound to tectonically predetermined structures that allow the highly fluid melts to rise rapidly and thus leave them no time to cool. If the melts reach the pressure range that results in the decomposition of the CaCO3 or the release of the CO2, a gigantic fan is created that opens the vent to the Earth’s surface by fragmenting the overlying cover, which explains the high content of wall rock xenoliths in the diatreme. If one now takes into account the phenomena known from technology that are associated with the transport of particles in flowing gases (fluidisation), then the tephras of volcanic pipes that can be found in the terrain can be easily explained. Furthermore, the detection of the carbon isotope 14C in carbonatitic tephra confirms the dissociation and recombination of CaCO3 during the eruption. For the Eifel, this means that the formation of the maars exclusively by phreatomagmatic processes must be reconsidered. This concept was already criticised in the work of Rausch et al. (2015) [52], but was only included in the work of Schmincke et al (2022) [53], in which the formation of maars in the Eifel by sudden magma degassing is also considered possible.

Acknowledgement

We would like to thank A.Pack, Georg-August University of Göttingen for massive support at measuring the oxygen und carbon isotopy. We would also like to thank L. Viereck for valuable advice during the preparation of the manuscript.

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The Psychological and Social Impact of Immigration Policies: A Minority Stress Perspective

DOI: 10.31038/PSYJ.2024653

 
 

The incoming Trump administration has outlined plans to implement a series of immigration policies emphasizing stricter enforcement measures, prioritizing mass deportations, enhanced border security, and the rollback of humanitarian programs [1]. Key components are expected to include the reinstatement of the “Remain in Mexico” program, requiring asylum seekers to await their court proceedings outside the United States; rolling back Temporary Protected Status (TPS) for individuals from certain countries; targeting the Deferred Action for Childhood Arrivals (DACA) program; reducing pathways for family-based immigration; re-introducing the Social Security Administration (SSA) no-match letters program to identify employees who are unable to establish continued authorization to work in the U.S. [2]; and deploying the U.S. military to aid in deportation efforts [3]. While framed as mechanisms to enhance national security and uphold legal frameworks, these policies are likely to foster a hostile social environment that disproportionately affects immigrant populations in the country. When analyzed through the lens of social determinants of health and minority stress theories, the potentially far-reaching implications of these policies on mental health become evident.

Social Determinants of Health and Hostile Environments

Dynamic systems theory asserts that humans are susceptible to their social environments, and challenging conditions can profoundly affect physical and mental well-being. Aligning with this perspective, the World Health Organization recognizes that social and community contexts- where individuals are born, grow, live, work, and age – significantly shape health outcomes [4]. Hostile social environments shaped by stigma, prejudice, and racism can act as substantial sources of chronic stress, with detrimental effects on targeted individuals’ well-being [5].

The incoming administration’s proposed policies will likely intensify these challenges by fostering environments steeped in fear and uncertainty. The plan for mass deportations with the potential use of the military would exacerbate the sense of insecurity among irregular immigrants, increasing their anxiety and stress levels. Programs like “Remain in Mexico” could disrupt the social and community contexts central to health, forcing asylum seekers into precarious living conditions that lack access to stable housing, healthcare, and safety. These policies are likely to serve as structural mechanisms that amplify the chronic stressors already affecting marginalized populations.

Minority Stress and Stigma Consciousness

The chronic stress experienced by individuals belonging to marginalized social groups is referred to as minority stress. The sources of minority stress are categorized into external (distal) and internal (proximal) stressors. External stressors include observable experiences such as rejection, discrimination, and acts of violence (Meyer, 1995) -all of which are likely to escalate under the incoming administration’s stricter enforcement measures.

Internal stressors, on the other hand, involve internalized perceptions of stigma and societal prejudices, such as internalized racism or homophobia (Meyer, 1995). This process, also referred to as stigma consciousness [6], reflects an individual’s heightened awareness of sociocultural stereotypes and biases targeting their group. For immigrants in the U.S., stigma consciousness is further intensified by public narratives that dehumanize them and portray them as “threats” to social order and public security (E.g., Haitian immigrants eating pets).

Political leaders and public figures significantly shape societal perceptions and influence inter-group dynamics [7]. Provocative rhetoric that labels irregular immigrants as “illegal,” “criminal,” or even “pet-eaters” harms both communities. It creates immigraphobia, an irrational fear of incoming migrants and immigration, by fostering perceptions of threat to national identity, public safety, or resource availability amongst the American public, creating divisions and mistrust. Also, it simultaneously fuels stigma consciousness, fear, and anxiety within immigrant populations. Furthermore, the psychological strain of concealing one’s vulnerable identity, such as an immigrant with irregular status hiding their identity due to the fear of deportation, will add to the cumulative burden of minority stress (Meyer, 1995).

Research shows that stigma consciousness and vicarious experiences of racism – such as witnessing or hearing about discriminatory policies or deportations- foster pervasive fear and anxiety (Yip et al., 2022). Even in the absence of direct personal attacks, the anticipation of rejection, hostility, discrimination, or expulsion can place individuals in a chronic state of stress and hyper-vigilance, with long-lasting consequences for their mental health and well-being. The psychological harm resulting from prolonged personal, collective, and vicarious experiences of racism and discrimination can culminate in racial trauma [8] with symptoms of hyper-vigilance to threats, flashbacks, avoidance of others, heightened suspiciousness, and somatic symptoms such as headaches, heart palpitations (Comas-Díaz et al., 2019). Furthermore, research has consistently correlated perceived racial discrimination with increased severity of anxiety, depression, and psychological distress [9-13]. These findings underscore the profound and multifaceted potential impacts of planned exclusionary policies on the mental health of immigrants, highlighting the urgent need for systemic changes to mitigate these stressors.

Broader Impacts on Immigrant Communities

The ripple effects of the above-mentioned hostile migration policies may extend beyond individuals, disrupting the social fabric of immigrant communities. Deportations and fear-based environments can erode collective resilience, weaken informal support systems, and instill mistrust in institutions such as healthcare and education. This mistrust may discourage immigrants from accessing essential services, including mental health support, further compounding the psychological toll. Fear of exposure or legal repercussions can exacerbate this avoidance, leaving individuals without critical resources to mitigate the stressors they face.

Conclusion

The incoming Trump administration’s planned immigration policies are likely to contribute to a hostile sociopolitical environment, intensifying stigma consciousness and minority stress among immigrant populations. Based on research and theory, these policies are expected to exacerbate mental health disparities while undermining community cohesion and individual resilience. The resulting cycle of fear and exclusion could perpetuate systemic inequalities, highlighting the urgent need for more inclusive and equitable approaches to immigration and public health. By addressing the structural and systemic factors that contribute to chronic stress and trauma, policymakers can foster environments that promote mental health and well-being for all individuals, regardless of their immigration status.

References

  1. Alvarez P, Mattingly P (2024) Donald Trump’s plans on immigration are coming into focus | CNN Politics. CNN Politics.
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  4. Cokley K, Krueger N, Cunningham SR, Burlew K, Hall S, et al. (2021) The COVID-19/racial injustice syndemic and mental health among Black Americans: The roles of general and race-related COVID worry, cultural mistrust, and perceived discrimination. Journal of Community Psychology. [crossref]
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  7. Newman B, Merolla JL, Shah S, Lemi DC, Collingwood L. et al. (2021) The Trump Effect: An Experimental Investigation of the Emboldening Effect of Racially Inflammatory Elite Communication. British Journal of Political Science, 51: 1138–1159.
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  10. Ertorer SE (2024) Racism and Mental Health: Examining the Psychological Toll of Anti-Asian Racism during the COVID-19 Pandemic. Genealogy, 8: 3.
  11. Haft SL, Zhou Q (2021) An outbreak of xenophobia: Perceived discrimination and anxiety in Chinese American college students before and during the COVID-19 pandemic. International Journal of Psychology, 56: 522-531. [crossref]
  12. Huynh MP, Yellow Horse AJ, Mai NM, Mantuhac J, Saw A (2023) Discrimination and psychological distress among Asian Americans during COVID-19: Gender differences in the moderating role of social support. American Journal of Orthopsychiatry.[crossref]
  13. Wenger MR, Lantz B, Gallardo G (2022) The Role of Hate Crime Victimization, Fear of Victimization, and Vicarious Victimization in COVID-19-Related Depression. Criminal Justice and Behavior, 49: 1746-1762.

POLÍTICAS PÚBLICAS E SAÚDE MENTAL: UMAREFLEXÃO SOBRE COTIDIANO E ACESSOÀS AÇÕES PREVENTIVAS DE ESTUDANTESUNIVERSITÁRIOS

DOI: 10.31038/IJNM.2024561

 

Resumo: No Brasil, é determinado pela Constituição Federal de 1988, que o direito à saúde seja viabilizado por meio do Sistema Único de Saúde (SUS) e que o acesso deverá ser universal, integral e gratuito, esse acesso é realizado através da ações das políticas públicas, que representam um conjunto de programas, ações e decisões tomadas pelos governos (federal, estadual ou municipal) com a participação, direta ou indireta, de entes públicos ou privados, essas políticas têm como objetivo garantir a cidadania e o bem-estar social. É de responsabilidade do Estado o desenvolvimento da política de saúde mental, a assistência e a promoção de ações de saúde às pessoas em condições de transtornos mentais, com a devida participação da sociedade e da família. A literatura científica apresenta que estudantes universitários estão fortemente sujeitos ao esgotamento mental e ao desenvolvimento de Transtornos Mentais Comuns (TMC), pois enfrentam, em seu cotidiano, diversas mudanças e adaptações com o início da vida acadêmica que trazem além da mudança do ensino médio para acadêmico, outras transformações que vão desde a saída do lar parental e organização financeira ao planejamento de excedentes horas de estudo. Essa tensão se estende ao longo do curso com as cobranças acadêmicas. Este ensaio teórico teve por objetivo refletir sobre as diversas questões do cotidiano acadêmico e o impacto na saúde mental de estudantes universitários durante o processo de formação. Foi realizada uma busca exaustiva pela literatura científica dentro da temática de saúde mental universitária, que identificou a população jovem adulta como grupo risco para o desenvolvimento de TMC, apresentado problemas relacionados como a ansiedade, depressão e suicídio. Estudos têm apontado que o jovem quando inserido na universidade tem mais chances de adoecimento do que os outros jovens da mesma idade que não cursam a universidade. O Censo de Educação Superior de 2019 apresentou que 8,6 milhões de jovens brasileiros estão matriculados na universidade. Esse ingresso na universidade é uma grande conquista, mas envolve mudanças, desafios e, também, adoecimento. Em todo o mundo várias pesquisas envolvendo estudantes universitários são realizadas, motivadas por situações psicossociais, econômicas, políticas e até mesmo questões referentes ao próprio ensino. Há diversos fatores associados ao sofrimento psíquico de estudantes universitários, maior vulnerabilidade do sexo feminino e uma variância da prevalência de depressão de 9,3% a 85% de acordo com a localidade, aspectos socioculturais e econômicos. É preciso que haja discussões entre gestores de saúde e as instituições de ensino superior sobre necessidades de saúde, singularidades de diversos grupos específicos, população jovem e estudantes universitários para implementação de programas e políticas de saúde mental com vistas à promoção da saúde, prevenção de riscos ao adoecimento mental, com participação e proatividade de todos, efetividade das ações de diagnóstico, acompanhamento e controle, assegurando aos universitários a conquista de uma nova profissão e o direito ao acesso universal à saúde e à educação com qualidade e como princípio fundamental para o desenvolvimento da cidadania.

Palavras-chave

Estudantes Universitários; Políticas Públicas; Saúde Mental; Sofrimento Psíquico; Universidade

REFERÊNCIAS

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Bridging Knowledge and Practice: Exploring Evidence Based Practice Implementation in Acute Care Nursing

DOI: 10.31038/IJNM.2024554

Abstract

Background: The effective implementation of evidence-based practices (EBPs) in healthcare is essential for enhancing patient outcomes. However, in acute care settings, the adoption of EBPs can be inconsistent due to organisational barriers, hierarchical structures, and limited resources. Interprofessional collaboration and continuous professional development (CPD) are critical in overcoming these challenges, empowering nurses to apply evidence-based knowledge in clinical practice.

Aim: This study aims to investigate how EBPs are implemented in two large acute care hospitals in East England, focusing on the roles of interprofessional collaboration, nurse led initiatives, and CPD in facilitating or hindering EBP adoption.

Materials and method: A collective qualitative case study design was used to examine EBP implementation across two hospitals with different organisational contexts. Data were collected through semi-structured interviews with nurses and physicians, and non-participant observation. Thematic analysis was conducted to identify key themes.

Results: The findings highlight that formal interprofessional collaboration, such as regular interdisciplinary meetings, significantly supports EBP adoption by enhancing communication and shared decision-making between nurses and physicians. However, professional silos and hierarchical barriers remain prevalent, often slowing EBP implementation and limiting nurse input. Nurses used their clinical expertise to independently advocate for and lead small-scale EBP changes, particularly in infection control and wound care, resulting in notable patient outcome improvements. CPD emerged as a powerful enabler, boosting nurses’ confidence and capacity to challenge outdated practices and advocate for evidence-based changes.

Conclusion: Formal collaboration structures and accessible CPD are essential to successful EBP implementation. Addressing hierarchical barriers and fostering interprofessional dialogue can improve the integration of evidence-based knowledge into routine care, empowering nurses as key drivers of change.

Background

Knowledge implementation stands at the forefront of healthcare advancements, essential for driving improvements in patient outcomes and elevating overall care quality [1-3]. Evidence-based practice (EBP) in nursing involves the integration of clinical expertise, patient values, and the best available evidence to inform clinical decision-making [4]. This approach not only enhances the effectiveness of patient care but also supports the professional development of nurses by grounding practice in research and evidence [1]. However, despite substantial evidence supporting EBPs and strong endorsements from health authorities like the National Institute for Health and Care Excellence (NICE) and the Nursing and Midwifery Council (NMC), there are significant barriers to EBP implementation in acute care settings, particularly in the United Kingdom [5]. These barriers often include organisational silos, hierarchical structures, and a lack of resources and time allocated for continuous professional development, which limit the capacity of nurses to fully integrate EBPs in routine practice [6,7]. Interprofessional collaboration has been shown to significantly enhance EBP implementation, as it encourages knowledge sharing and supports decision-making across disciplines [8]. Studies have demonstrated that healthcare environments promoting interdisciplinary teamwork foster more effective communication, increase the uptake of EBPs, and ultimately improve patient outcomes [9]. Yet, evidence also highlights that healthcare organisations often operate within rigid professional silos, which impede the collaborative processes essential for EBP integration [10,11]. In particular, nurses may face challenges when their input is undervalued or dismissed in favour of physician-dominated perspectives, limiting the full utilisation of their expertise and knowledge in decision-making [2]. The persistence of these silos suggests a gap in understanding the mechanisms by which interprofessional collaboration can be consistently and effectively integrated into acute care practices to support EBP.

Nurses play a pivotal role in identifying care gaps and initiating evidence-based changes due to their continuous patient interactions and hands-on care delivery experience [12]. Studies indicate that when nurses are empowered with autonomy and professional development opportunities, they can act as change agents, advocating for and implementing EBPs independently, which positively impacts patient care [13,14]. Nonetheless, despite the recognised value of nurse-led EBP initiatives, healthcare systems often lack structures that empower nurses to independently lead such efforts, particularly in resource-limited environments where formal professional development opportunities may be scarce [15]. This challenge is compounded in acute care settings where workload pressures and staffing shortages can further limit the ability of nurses to dedicate time to EBP [6]. Addressing these barriers through targeted support, professional development, and restructuring of roles could enable nurses to make greater contributions to evidence-based improvements. A key factor in empowering nurses to lead EBPs is continuous professional development (CPD), which has been shown to significantly increase confidence, advocacy skills, and the ability to challenge outdated practices [16]. However, studies highlight disparities in access to CPD, particularly in settings with limited resources [17]. While some research advocates for structured CPD to enhance EBP implementation [18], there remains a lack of comprehensive understanding regarding the ways CPD and nurse empowerment impact EBP adoption in under-resourced acute care settings. Given the crucial role of nurses in direct patient care, addressing the gap in CPD access and exploring its impact on EBP utilisation are essential for supporting sustained improvements in healthcare quality. In response to these gaps, this study aims to investigate the dynamics of interprofessional collaboration, nurse-led initiatives, and professional development as facilitators and barriers to EBP implementation in acute care settings. By examining these factors across two large hospitals in East England, this study seeks to provide insights into the specific organisational and professional elements that enable or hinder the effective integration of EBPs. The findings will contribute to a deeper understanding of how healthcare organisations can leverage interprofessional collaboration, empower nurses, and enhance CPD to optimise patient care and support sustained EBP adoption.

Material and Methods

Research Design

This study utilises a collective qualitative case study design. The collective case study approach is ideal for examining multiple cases with shared characteristics, allowing cross-case comparison and deeper analysis of complex phenomena like EBP in healthcare settings [19]. The qualitative case study design ensures a thorough and nuanced understanding of EBP implementation challenges across diverse hospital environments [3]. The study followed the Consolidated Criteria for Reporting Qualitative Research (COREQ) [20].

Study Settings

The study took place between September 2017 and July 2023. Purposive sampling was conducted in two acute care settings in the East Midland region of England. The sample included one mid-sized general hospital (600 beds) and one large general hospital (700 beds), both selected to represent diverse leadership experiences and organisational contexts. These hospitals, the largest in the region, shared similar geographical and socio-cultural characteristics and were chosen to explore EBP in a complex clinical environment with rich data potential. The decision to focus on these two hospitals was driven by practical considerations of cost, time, and accessibility, aligning with Stake’s [21] recommendation to select cases that are both welcoming and feasible for research.

Sample Size and Participants

A total of 23 staff nurses (SNs) and nurse managers (NMs) and 2 Physicians participated in the study. The inclusion criteria were: (1) individuals with at least two years of experience working in these settings; and (3) those willing to participate and who signed the informed consent form. Participants were excluded if they had to withdraw due to work-related commitments or health issues during the interview period. Tables 1 and 2 present the demographics of participants. Participants in both study sites were similar. The participants’ years of experience ranged from 6 to 35 years, reflecting a broad spectrum of clinical expertise across both cases.

Table 1: Participants’ Demography (Site 1).

Table 2: Participants’ Demography (Site 2).

Data Collection

Data were collected through semi-structured interviews and non-participant observation (Table 3), enabling triangulation and validation of findings [22]. Interviews were guided by an interview guide (Table 4), recorded, and transcribed. Non-participant observation captured real-life interactions, providing insights into the practical implementation of evidence-based practices. In both sites, the lines of communication for EBPs were well-established, with the Research and Development (R&D) Unit playing a key role in facilitating communication and disseminating evidence-based guidelines. The R&D and Practice Development Units were also involved in developing local evidence guidelines for their respective teams.

Table 3: Data sources

Table 4: Interview Guide

Data Analysis

Braun and Clarke’s [23] thematic analysis framework was employed to systematically organise the finding following six key phases. The process began with familiarisation, where interview data, field notes, and observations were reviewed to understand participants’ experiences with EBP. During coding, key segments were labelled, including ‘collaborative protocol development’ ‘exclusion from decision-making’ and ‘empowerment through training’. These codes informed broader themes in the next phase: ‘Facilitators and Barriers to Knowledge Implementation’ ‘Nurses as Drivers of Knowledge Implementation’, ‘Enhancing Collaboration and Knowledge Sharing’, ‘Empowerment through Professional Development’, and ‘Transformative Impact of Nurse-Led EBP’. Themes were then reviewed for coherence and refined for clarity, defining each as it related to the study’s focus. For instance, ‘Knowledge sharing through collaboration’ addressed co-developed protocols, while ‘Barriers created by silos’ highlighted decision-making exclusions. In the final report, these themes collectively illuminated facilitators, barriers, and the impact of nurse led EBP, presenting a cohesive narrative on EBP integration in acute care settings. Overview of the key themes is presented in Table 5.

Table 5: A summary of key themes

Ethical Considerations

This study followed the ethical principles of the Declaration of Helsinki of 1964 and received approval from the University of Northampton Research Ethics Committee. Each hospital’s management also granted permission for participant recruitment. Broader ethical approval was not required, as the study did not involve minors, clinical trials, or pose any risks to participants, per UK regulations. Participants received electronic and written invitations detailing the study’s purpose, confidentiality, data handling, and their right to withdraw without consequences. Informed consent was obtained in line with GDPR. The researcher shared their professional background and explained the study’s aims to build trust [22], ensuring anonymity in reporting. All data will be securely stored and destroyed after publication, and participants were treated with respect throughout.

Rigour and Reflexivity

The study adhered to principles of credibility, transferability, dependability, and confirmability [22]. Triangulation, prolonged engagement, and multiple data collection methods, including interviews and observations, were employed to capture diverse perspectives. Spending eight months in the field enhanced credibility by providing a thorough understanding of issues affecting EBP implementation. The research process was meticulously documented, with detailed contextual information and a clear audit trail, ensuring transferability and potential replication [21]. Participant quotes supported data analysis, ensuring transparency [19]. Reflexivity was maintained through explicit acknowledgment of the study’s philosophical foundations, and a research diary preserved consistency during analysis. Finally, the COREQ guidelines were followed in reporting the qualitative results [20].

Findings

The findings reveal that effective knowledge implementation in acute care is influenced by interprofessional collaboration, nurse-led initiatives, and professional development. Key themes include the role of collaboration between nurses and physicians in facilitating knowledge sharing, though hindered at times by professional silos; nurses’ proactive leadership in driving EBPs, particularly in infection control and wound care; and the empowering effect of continuous professional development, which equips nurses to confidently advocate for and apply evidence-based changes in patient care.

Facilitators and Barriers to Knowledge Implementation

Findings from both sites show that the effective implementation of EBPs was influenced by the degree of interprofessional working between nurses and physicians. While collaboration often facilitated the integration of new practices, barriers still emerged where professional silos and communication breakdowns occurred. This theme explores how interprofessional collaboration supports or hinders the implementation of EBPs and highlights the challenges faced by nurses in these collaborative processes.

Knowledge Sharing Through Collaboration

Interprofessional collaboration was a crucial factor in facilitating knowledge implementation at both sites. The sharing of expertise between physicians and nurses allowed for the co-development of new care protocols, particularly when teams had clear communication pathways. In site 1, nurses shared: “…we worked with the doctors on a new pain management protocol, and by discussing the evidence together, we were able to agree on a more effective approach. It felt like real teamwork” (Interview, Senior Nurse, S1). Similarly, I site 2, collaboration led to quicker decision-making: “…the consultants started involving us in discussions about infection control measures…we shared our observations, and they adjusted the protocols…that kind of collaboration made a huge difference.” (Interview, Infection Control Nurse, S2). This finding demonstrates how interdisciplinary collaboration fosters a mutual understanding and respect for each profession’s expertise, enabling smoother EBP implementation.

Barriers Created by Professional Silos

Despite the benefits of collaboration, professional silos were a significant barrier at both study sites, with nurses often excluded from decision-making processes. This resulted in slower implementation of evidence-based changes and frustration among nursing staff. In site 1, nurses expressed that they “had solid evidence for a change in wound care practice, but we weren’t involved in the initial discussions…it took weeks for the doctors to acknowledge our input, which delayed everything” (Interview, Senior Nurse, S1). Similar experiences were reported in site 2 with nurses stating that they “…were pushing for months to update our catheter care protocol, but we weren’t getting feedback from the doctors…they would discuss it among themselves and leave us out, which slowed down the process.” (Interview, Nurse Manager, S2). These quotes highlight the negative impact that professional silos have on knowledge implementation, with nurses feeling marginalised and unable to influence critical decisions, despite having evidence-based insights to offer.

Nurses as Drivers of Knowledge Implementation

While hierarchical barriers remain, nurses at both study sites played a proactive role in driving the implementation of EBPs. Their clinical experience, patient proximity, and understanding of care needs positioned them as key advocates for change. This theme explores how nurses used their expertise to implement EBPs, even when formal collaboration with physicians was lacking.

Leveraging Clinical Expertise to Advocate for Change

Nurses at both sites demonstrated the capacity to introduce new practices based on evidence, using their clinical expertise to identify care gaps and push for changes. Even in environments with limited formal collaboration, nurses were able to initiate small-scale, impactful interventions. In site 1, Ward Managers seem to have utilised their expertise to advocate for EBP implementation. For example, one of the nurses expressed “…I noticed that our pressure ulcer incidence was increasing, so I introduced a new prevention strategy…the doctors were hesitant at first, but we showed results quickly, and it became standard practice” (Interview, Ward Nurse, S1)

Nurses in site 2 appeared to have done utilised similar strategies: “we started trialling a new dressing technique based on research, even before it was formally approved…once the physicians saw the improvement, they accepted it as part of our wound care protocol” (Interview, Senior Nurse, S2). These examples illustrate how nurses, using their practical knowledge, were able to implement EBPs independently, improving patient outcomes even without immediate approval from physicians.

Integrating EBP into Routine Care

Nurses at both sites consistently integrated evidence into daily care activities, often making subtle changes that did not require formal approval but had a significant impact on patient care. These routine adaptations of EBPs highlight nurses’ roles as continuous drivers of care quality improvements. In site 1, an observation of ward round revealed some clinical procedures related routine knowledge implementation: “…during rounds, a nurse adjusted a patient’s medication schedule to align with the latest evidence on pain management, even though the consultant had not yet approved the change. It made a noticeable difference in the patient’s comfort” (Observation, Ward Rounds, S1). A similar scenario played out in site 2 where during observation “nurses began closely monitoring post-surgical patients for early signs of infection, following new evidence on early detection, even though the formal guidelines hadn’t yet been updated” Observation, Post-Surgical Ward, Site 2). These examples demonstrate how nurses are able to integrate evidence into routine care processes, subtly driving improvements in patient outcomes, even when formal approval or recognition from physicians is delayed.

Enhancing Collaboration and Knowledge Sharing Through Interprofessional Initiatives

While professional silos remain a challenge, both study sites showed promising examples of initiatives aimed at fostering better collaboration between nurses and physicians. These initiatives helped to break down barriers, promote knowledge sharing, and accelerate the implementation of EBPs.

Formal and Informal Collaboration

A structured collaboration initiatives were established in site 1, with regular meetings to discuss new research and evidence-based changes in practice. This formal collaboration significantly improved communication and sped up the adoption of EBPs. One of the physicians shared: “…we’ve started having weekly meetings where the whole team, including nurses, discusses new research…it’s really improved our teamwork and made it easier to agree on new practices.” (Interview, Physician, S1). On the other hand, collaboration was less formal in site 2, but still made a positive impact as expressed by some of the nurses: “|…we don’t have regular joint meetings yet, but I’ve noticed that the doctors are increasingly asking for our input during rounds…it’s a good start” (Interview, Senior Nurse, S2). These examples suggest that while formal structures may enhance collaboration, even informal efforts can foster better communication and improve the implementation of EBPs.

Creating Interdisciplinary Knowledge Networks

Both sites showed an emerging recognition of the need for interdisciplinary knowledge networks that enable the continuous exchange of information and expertise across professional boundaries. In site 1, one of the nurses described the value of these networks as positive. “…we set up a group where nurses and doctors present the latest evidence guideline, they’ve come across…it’s helped bridge the gap between our roles and encouraged us to adopt new practices quicker.” (Interview, Senior Nurse, S1). A similar approach was developing in site 2 as indicated by the quote: “…whenever we get the chance to sit down together and discuss cases, it leads to real learning…that’s when the best ideas come up, and we’re able to implement them” (Interview, Nurse Manager, S2). The recognition of interdisciplinary knowledge sharing at both sites emphasises the importance of creating formal structures to support this collaborative learning, which is crucial for timely and effective EBP implementation.

Empowerment Through Continuous Professional Development

Education and continuous professional development are critical for empowering nurses to lead the implementation of EBPs. Both sites recognised the importance of investing in nurse education to strengthen confidence, knowledge, and the ability to advocate for evidence-based changes.

Education as a Driver of Confidence

Structured professional development opportunities, including workshops and training on EBPs, had a positive impact on nurses’ ability to implement new practices confidently. One of the nurses shared: “…after attending regular workshops on EBP, I feel much more confident bringing new ideas to the table…it’s made a huge difference in how we approach care” (Interview, Nurse Manager, S1). In site 2, education appeared to be self-driven, with nurses seeking out external opportunities: “…we don’t have as many formal training programmes, so we’ve had to find our own opportunities for development…it’s been challenging, but it’s also made us more proactive” (Interview, Senior Nurse, S2). These differing approaches highlight the need for more structured educational support at all sites to empower nurses in knowledge implementation.

Building Advocacy Through Education

Professional development not only improved knowledge but also empowered nurses to challenge outdated practices and advocate for EBPs. Nurses across both sites reported feeling more equipped to engage with physicians after receiving training. One of the nurses remarked: “…the EBP training gave me the tools I needed to confidently push for changes in the ward…now, I’m not afraid to challenge practices that don’t align with the evidence…” (Interview, Nurse, S1). Similarly, in site 2 “…the more I learn about the latest research, the more I feel I can make a real difference in care, even if it means going against established practices” (Interview, Senior Nurse, S2). These findings demonstrate how education enhances nurses’ capacity to advocate for evidence-based care and challenge traditional, less effective practices.

Transformative Impact of Nurse Led Knowledge Implementation

When nurses are empowered to implement EBPs, the results are transformative, both in terms of patient outcomes and the evolution of nursing practice. This theme explores the direct impact of nurse-led knowledge implementation on patient care and the professional development of nursing teams.

Improved Patient Outcomes

Both sites reported significant improvements in patient outcomes following the successful implementation of EBPs led by nursing teams. These improvements were particularly evident in infection control and wound care management. In site 1, a nurse shared: “…since we introduced the new infection control guidelines, we’ve seen a dramatic reduction in hospital-acquired infections…it’s been one of our biggest successes” (Interview, Infection Control Nurse, S1). In site 2, similar results were observed in post-operative care: “…the changes we made to wound care, based on the latest evidence, have reduced complications for our patients. It’s really shown how powerful EBPs can be” (Interview, Senior Nurse, S2). These success stories highlight the significant positive impact of nurse led EBP implementation on patient safety and care quality.

Transforming Nursing Practices

In addition to improving patient outcomes, nurse led EBP implementation has transformed nursing practices at both sites. Nurses reported feeling more empowered and respected within their teams, as their roles evolved from task-oriented responsibilities to research-driven care leadership. In site 1, a nurse reflects: “…implementing EBPs has changed how we work…it’s given us more credibility and made nursing more evidence-driven, which is how it should be” (Interview, Nurse Manager, S1). A similar sentiment was expressed in site 2: “…we’re no longer just following orders…we’re part of the decision-making process, and it’s changed how we see ourselves as professionals” (Interview, Senior Nurse, S2). These transformations underscore the critical role nurses play in leading the adoption of EBPs and improving the overall quality of care through evidence-driven practices.

Discussion

The findings of this study reveal complex interplays between interprofessional collaboration, hierarchical structures, and nurse-led initiatives in implementing EBPs within acute care settings. Key themes such as knowledge sharing, barriers due to professional silos, and the role of CPD emerged, all of which reinforce the necessity of a collaborative and empowering healthcare environment for EBP. These findings align with previous research while also highlighting unique challenges and opportunities within the study sites. The findings indicate that interprofessional collaboration significantly facilitates EBP adoption, a view supported by Reeves et al.., [8], who argue that interprofessional teamwork enhances knowledge exchange, ultimately leading to improved patient outcomes. Regular interdisciplinary meetings allowed nurses and physicians to share insights and align protocols, illustrating how formalised structures can improve communication, a point echoed by Grimshaw et al., [11]. However, the lack of formal collaboration structures slowed EBP adoption, suggesting that the absence of structured interactions may undermine the speed and efficacy of implementing evidence-based changes. Sullivan et al., [10] similarly argue that professional silos and the absence of regular interdisciplinary meetings can hinder EBP adoption, creating inefficiencies in decision-making. This comparative insight supports the notion that effective collaboration is contingent on formal structures that facilitate dialogue across professions, yet the findings also suggest that even informal collaboration, as observed at Site 2, can initiate positive change, albeit more slowly. Both study sites reported significant barriers due to professional silos, with nurses often excluded from decision-making processes. This aligns with the work of Dunn et al., [24-29] and Ominyi et al., [2], who found that hierarchical structures in healthcare often subordinate nursing perspectives to medical authority, limiting nurses’ capacity to advocate for EBPs effectively. The hierarchical barriers evident in this study exemplify how power dynamics in healthcare can stifle nurses’ evidence-based suggestions, even when such recommendations have the potential to improve patient outcomes. Brown et al., [15] also identified these silos as sources of frustration, as healthcare workers experienced delays in practice change implementation due to a lack of engagement and feedback from other professional groups. These barriers suggest that healthcare organisations must address hierarchical dynamics to facilitate a more inclusive decision-making process, enabling nurses to participate fully and contribute their insights into patient care practices.

Despite the hierarchical constraints, nurses at both sites demonstrated a proactive approach to EBP, using their clinical expertise to introduce evidence-based changes in infection control and wound care. This finding aligns with Harvey et al., [1], who highlight the critical role of nurses as change agents in direct patient care. Moreover, Gerrish et al., [6] found that empowering nurses to act independently often led to improved patient safety and care outcomes. Nurses in this study leveraged informal knowledge-sharing networks to drive improvements in practice, particularly when formal approval from physicians was not immediate. This self-driven initiative underscores the potential of nurse-led interventions in advancing EBP, even within restrictive organisational structures. The findings emphasise the importance of CPD in empowering nurses to implement EBPs confidently. Study findings reveal that structured CPD opportunities can boost nurses’ confidence in suggesting evidence-based changes, a result consistent with McCormack et al. [16], who argue that CPD enhances practitioners’ capacity to challenge outdated practices. However, Site 2’s reliance on self-driven educational pursuits illustrates the limitations of under-resourced environments, where formal CPD support is sparse. The disparity between the two sites reinforces Melnyk and Fineout-Overholt’s [4] argument that healthcare organisations must invest in continuous, structured professional development to support sustained EBP integration. Without organisational support for CPD, nurses may struggle to access the resources and training necessary to lead evidence-based improvements effectively. The study highlights the importance of interprofessional collaboration and nurse-led initiatives in effective EBP implementation. Formal interdisciplinary meetings enhance communication, decision-making, and reduce silos, thereby improving patient care. Additionally, investing in structured CPD for nurses builds confidence and strengthens their advocacy for evidence-based changes. Healthcare organisations should prioritise these areas to support sustained EBP integration and optimise healthcare delivery. For future research, examining ways to minimise hierarchical barriers and exploring the long-term impact of collaboration structures on EBP are essential. Research on structured CPD programmes, particularly in resource-limited settings, and identifying best practices in nurse-led EBP initiatives could further support patient care improvements.

Strengths and Limitation

This study’s strengths lie in its use of a collective qualitative case study design, providing an in-depth exploration of knowledge implementation across diverse acute care settings. Through triangulation of data from interviews, observations, and document analysis, the study ensures a comprehensive understanding of facilitators and barriers in EBP adoption. However, the study has limitations; the perspectives primarily represent staff nurses, nurse managers, and physicians, potentially overlooking insights from other key stakeholders, such as patients and policymakers, which could further enrich the understanding of interdisciplinary challenges in knowledge implementation.

Conclusion

This study highlights the importance of interprofessional collaboration, CPD, and nurse empowerment in implementing EBP within acute care settings. However, challenges persist, particularly regarding hierarchical barriers and inconsistent CPD support. Formal structures, such as interdisciplinary meetings, significantly enhance EBP adoption, though informal collaboration can still foster progress. Findings emphasise that nurses, even with limited formal support, can lead impactful EBP initiatives, illustrating their role in advancing patient outcomes. Further research should address strategies to reduce professional silos and support structured CPD, especially in resource-limited environments, to enable sustainable, nurse-led EBP integration in healthcare.

Acknowledgements

We wish would appreciate all nurses who participated in this study.

Author Contributions

JO and NA contributed to the conceptualisation and methodology of this study. JO and NA were involved in the investigation and validation of the results. JO and NA were responsible for data curation and formal analysis. JO contributed to the drafting of the manuscript, while NA reviewed and edited. JO supervised the study and provided necessary resources. All authors have read and approved the final version of the manuscript.

Funding

None received.

Data Availability

The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.

Declarations

Ethical Approval and Consent to Participate

This study received approval from the University of Northampton Research Ethics Committee. Each hospital’s management also granted permission for participant recruitment. Broader ethical approval was not required, as the study did not involve minors, clinical trials, or pose any risks to participants, per UK regulations. They were informed that they could refuse to answer any questions or withdraw from the study at any time. All recordings were securely stored in accordance with confidentiality principles.

Consent to Publish

Not Applicable.

Competing Interests

We declare no conflict of interest.

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Information Architecture for the Management of Collaborative Information to the Citizen on Health Care Issues in the Areas of Pinar del Rio Municipality

DOI: 10.31038/IJNM.2024553

Abstract

Introduction: Information Technologies are currently essential elements for the improvement and development of a country, on the other hand, Cuba has identified from very early on the need to introduce Information and Communication Technologies in social practice and achieve a digital- technology culture as one of the crucial characteristics of the new man. Cuba is moving towards electronic-government, achieving digital technology and information literacy in the decisive processes, creating channels to increase citizen participation. How to contribute to the management of collaborative information to the citizen on health care issues in the areas of Pinar del Rio municipality?

Objective: to develop the Information Architecture for the Citizen Collaboration in the health care issues in the areas of Pinar del Rio municipality.

Methods: a Technological Innovation Research on information management in the health care areas of the municipality under study is carried out following the methodology of software development for Extreme Programming, and applying theoretical and empirical methods for the analysis, review and modeling of the processes under computerization.

Results: it was found that the proposal of information technology is based on managing the information of the different medical services, serving as a tool to help to the organization of the healthcare system and make it more efficient.

Conclusion: a computerized prototype was created that will avoid the gathering of people who come to the institutions in search of answers to questions directed to knowledge or orientation for a determined problematic on purpose of the community projection.

Keywords

Access to information, Software design, Software, Medical informatics applications, Information technology

Introduction

Information and Communication Technologies are currently fundamental elements for the improvement and development of a country [1]. In this sense, Cuba has identified from a very early stage the convenience and need to dominate and introduce social practice ICT and achieving a digital culture as one of the essential characteristics of the new man, which would facilitate society to get closer to the goal of sustainable development [2,3]. In the field of health, it offers a strength in technological progress that presents positive experiences worldwide [4,5]. The most optimistic projections in this regard suggest that a computerized and interconnected world not only ensures growth and development, but which also guarantees improvements in access to facilities that enhance the quality of life, and facilitate broad access to digital content and services for citizens [6,7]. The effort that the Cuban State has made to support the computerization of society is a fact. Concrete actions are developed throughout the country to conclude the initial stage of electronic government [8], it is not only to create the platforms, but also that they work with good practices, provide digital services to the population and interact with the people. In this way, digital and information literacy is achieved as the ability to locate, organize, understand, evaluate and analyze information through digital technology, create channels that allow increasing citizen participation [9,10]. The creation of a computer prototype [11], for the people of Pinar del Río who access the health areas of the main municipality of the province, allows the description of many useful processes to any citizen [12-14], and the possibility of having of them in a single and integrating platform [15,16]. This prototype is based on improving social welfare and the actions carried out by an informed population, in order to provide services and information to citizens, increase effectiveness and efficiency of public management [17], and increase the transparency of the sector with the participation of all communicators who require some information [18-20]. In the different health areas of the main municipality, several processes are developed, this research is immersed in the computerization of each of them, which are aimed at the satisfaction and knowledge of the citizen, maintaining the health of the population, with health promotion and community participation, with the planning, organization, monitoring and evaluation of the processes.

Whose objective is aimed at Electronic Government, where they can streamline, improve, adapt, socialize and reduce costs of the processes and/or activities of the public system, motivated by the use of advances in ICT, through channels that allow increasing participation citizen, with the aim of improving the health status of the population, increasing the quality and satisfaction of the people with the services provided, making the system efficient and sustainable and guaranteeing its development, through community projection. This will be achieved by bringing health services to the community, through the different medical specialties, and with the strengthening at all times of actions aimed at the well-being of citizens who require health services. In each polyclinic, health services are brought to the community with community projection where each specialty such as Surgery, Endocrine, Cardiology, Urology, Traumatology, Dermatology, Menstrual Regulation, Orthopedics, Adult and child Traumatology, Angiology, Nephrology, Gastroenterology, Rheumatology, Adult and child allergy, Optometry, ENT, Ophthalmology, Infertility Consultation, Driver’s License. They are carried out on different days of the week, when the patient is referred from the medical office to the area, or due to medical expenses, this arrives with the referral for the specialist to the admission department of the health unit, the Registration with the patient’s data, identity card, name and surname, doctor’s office, referred by, age, consultation date and time, and the patient is verbally notified of the day the consultation is scheduled. The patient goes to the polyclinic on the day scheduled with the specialist, without knowledge of the place or location of the consultation and the doctor who is going to attend him, as well as the regulations that are established, in addition to the different services that are provided in the institution. What results in a problem in terms of organization and rationalization of the services provided. The problem detected in the development of electronic government in the health sector justifies this research, developed with the participation of citizens who go to the different services. The work is the result of a research project of the master’s degree in Health Informatics, with the aim of developing the information architecture for citizen collaboration in health matters in the areas of the Pinar del Rio municipality.

Methods

The research is due to a technological innovation project for the development of a computer application for the management of Citizen Collaboration on health issues in the areas of the Pinar del Río municipality, in the period from 2019 to 2021, based on the study of the current needs and shortcomings of the population, in the four polyclinics of the Pinar del Rio municipality. The results presented correspond to the analysis and design stages of the project, and they used theoretical research methods such as historical-logical and induction-deduction, to capture functional and non-functional requirements, as well as modeling. of the information architecture on which the Citizen Collaboration management process in the areas of the municipality is based. Among the empirical methods, the following were used: the interview with citizens who require health services, as well as the bibliographic review during the analysis and design of the prototype of the computer application During the course of this research, periodic bibliographic reviews of articles in magazines, national newspapers, scientific publications, related to electronic government in Cuba, development and computerization of a society, literacy of the population regarding digitization of processes, web applications were carried out to manage information. The DeCS health descriptors were used as search strategies to determine keywords, databases such as SciELO, by indexing the terminologies from the common language to the permuted language. For the modeling of the prototype object of study and research, the following trends were used for its design and analysis: extreme XP programming, as an agile development methodology whose main objective is to increase productivity when developing a software project, to model, build and document the elements that make up a software product that responds to an object-oriented approach; the Unified Modeling Language (UML), for the capture of requirements, analysis, design and interoperability with other applications with a multiplatform support. ENTERPRISE ARCHITECT, one of the UML CASE tools, was also used. For the simulation of the behavior of the interfaces, the design of the wireframes and the basic prototype, Axure RP was used as a development tool.

Results

In the health sector of the Pinar del Rio municipality, several processes are developed in the admission area related to citizens who request medical appointments for the different consultations that are developed. Next, the relationship of the process to understand more clearly the aspects worked, starting from the citizen who refers his personal data to the worker who works in admission and in turn verifies if there are shifts for the required consultation, the reservation and notification of the same The research determined through the analysis of the process, the procedures, methods and techniques for solving the problem, based on the modeling of the collaborative management process with the citizen on health issues in the areas of the Pinar del Rio municipality, with the implementation of the following requirements that describe the functionality of the software. The functional requirements that the prototype must meet are nothing more than the capabilities of the product to satisfy both the customer and the end users.

Functional Requirements

R1. Authenticate User

R2. Change Password

R3. Manage Citizen Data

R3.1. Insert Citizen Data

R3.2. Modify Citizen Data

R3.3. Delete Citizen Data

R4. Manage Community Projection

R5. Show Reports

R5.1. Patient Consultations

R5.2. Patients by Date

R5.3. Query by Date

R5.4. Referred Patients

R5.5. Patients by Municipality

R6. Perform Searches

R6.1. Search Patient

R6.2. Search Patient Month

R6.3. Search Patient Office

R6.4. Search Patient by Sex

R6.5. Search Patient by Age Group

R7. Shift Notification

R8. Consult Help

The information architecture was designed, for which the analysis and design stages of the software development process were executed. The actors of the system are defined who constitute the entity that is in charge of the realization of one or more of the functionalities that must be executed. Two actors are defined in the proposed software: the citizen, who is the person who can only enter their personal data and the desired query, and receive notification of it. The admission staff is in charge of managing all the information in the application, that is, inserting, modifying and deleting, in addition to changing the password, and accessing all the consultation options, searches provided by the system and obtaining reports. The functionalities diagram based on the XP methodology is shown, with the relationship between the actors and the different processes of the proposed system.

Description of the System Functionalities

The tool is designed to satisfy the information management requirements of the Citizen Collaboration on health issues, by providing services to the community. With the implementation of the software, which is designed to work from the web, through the network of networks on any platform, which for Pinar del Río citizens who access the health areas of the head municipality of the province allows the description of many useful processes, and the possibility of having them in a single and inclusive platform and the actions carried out for the sake of an informed population, in order to provide services and information to citizens, increase the effectiveness and efficiency of public management. With an informed population, resources, development and knowledge are gained. At the same time, it allows the citizen from his home, work center, recreational area, through the technological development that the province has in terms of info-communications. This prototype manages information regarding health issues in terms of information from polyclinics on location, mission and vision, structural and organizational composition, in addition to the services provided, information related to primary health care, epidemiological alerts, programs specialized, and everything concerning the community projection.The system is designed so that any user can access its interface, select the health area and view the information options that it provides, the citizen must select the health area to which they belong in order to access it, obtain information on health issues and be able to request any consultation related to community outreach. The citizen presses on the community projection button, a window is displayed with the relationship of the consultations by specialty, with the time, day and frequency per week, as well as their location. It must be selected with a click on the query button to schedule a desired shift. The functionality for the Citizen Data management is essential for the beginning of each process, Once the health area has been selected, the citizen selects the consultation to which he was referred to program the doctor’s turn, the system refers you to a new window, to fill in the data requested by the form, name and surname, identity card, municipality, doctor’s office, age, sex, referred by, specialty. Once these data are entered, the citizen’s e_mail and contact telephone number is required so that he or she is notified of the turn for consultation. The citizen must fill in all the fields that present an asterisk (*), these data being mandatory. The system specifies the mandatory fields that must be filled in. When any field is left blank, the process does not end. The system sends you a message.

The system sends a message if when you are going to enter the identity card number you put letters instead of numbers and if any character is missing it returns a message specifying the error. When the citizen is going to enter the date for the consultation. Where the system specifies that only 24 appointments can be given per consultation and the 24 patients are already complete for that date. The system sends a message specifying that there are no available shifts for that date that you must select another and disables the remaining fields. If there are shifts for the selected date, it allows the introduction of the citizen’s email and contact telephone number, captcha the image provided by the system to make sure that it is not a robot and if a user. The citizen clicks on the save button where this information is stored in the Database and the fields are cleared. Once all the data has been entered correctly, click on the Send Notification button, the system sends a notification message of the shift via email with the confirmation of the requested medical shift. The admission staff for each health area enters the prototype through a form where they enter their Name and Password in the corresponding text boxes when pressing the Enter button. If the user is recognized by the application (he is registered in the database of users with access), it shows him the corresponding interface, according to his role in the application. If, on the other hand, the user is not recognized, the application displays an error message “Incorrect username and/or password” in which it warns the user that they do not have rights to access the management of the processes that are develop in the area. The functionality of the admission staff shows the data of the patients that were previously inserted by the citizen, and that are stored in the database; the Reports that the system allows, as well as the Searches to it. It also allows you to change the password periodically as a security measure, and consult the help of the application for any questions in this regard. The application shows the registry of all the patients who were introduced to the system by the citizen himself with his personal data, in addition to the community projection or consultation to which he was referred to be evaluated with the specialist. It allows the admission staff to modify some patient data or delete the unnecessary record. To modify the data of a patient or citizen in the system, the admission staff must select the name of the patient to be modified. As long as the patient has not been selected, the rest of the form data is disabled. Among the functionalities of the application are the Reports, which are aimed at providing information regarding the information management process with the citizen in relation to community projection. The event starts when it is necessary to know, according to a specific query, the patients that are registered. The system sends a message to select the consultation, and returns a list of all the patients that are registered for the selected consultation. In the same way, to know the patients who are registered for a previously selected date.

Discussion

The research carried out is due to a technological innovation project for the implementation of a computer application for citizen collaboration management in the health areas of the Pinar del Rio municipality. It is necessary to computerize the development of collaboration with the citizen on health issues in the different areas of the Pinar del Río municipality, which allows managing all the information of the different medical services, therefore it constitutes a tool to help organize the system and provide you with more efficiency. The absence of a computerized system for the management of information to the population results in disorganization, the accumulation of personnel who go to the institutions in search of answers about the consultations of a specialty, the time and location, the procedure to be followed in mind to be attended by trained personnel to provide quality service. As part of the study of the object of computerization, a review of health sites with related topics was carried out that provide information to citizens who interact with software used in the country. The website entitled, National and Foreign Health Sites, stands out, showing a compilation of links to sites on public health issues in Cuba Among them are the Provincial Nodes of Infomed, Health Specialties and Topics, Sites of Interest, Medical Societies, Health Legislation and Policies, Hospitals and Institutes, Faculties of Medical Sciences, as well as foreign sites on health in Spanish [15].)

The analysis carried out on similar sites that provide information to the population on health issues, allowed to shape the structure of the application according to the citizens of Pinar del Río, whether they refer to information of a general nature from the institutions, such as those related to health care properly with the community projection. Where it could be verified that, in the confronted sites, the information is very general and with the characteristics of each unit. In the province of Pinar del Rio there is El Portal del Ciudadano Pinareño [10], which is part of the strategy drawn up by the Government in the province of Pinar del Río to implement electronic governance. More than thirty entities subordinate to the Council of the Provincial Administration (CAP) and other organisms of the province participate in this project. In addition to showing the work of the Government, in favor of the well-being of citizens and society in general. Existing computer systems do not meet the expectations of the health sector because the population needs to be more documented, to know everything concerning community projection and how health services are brought to the community, through plans, services or programs than institutions. All with the aim of improving their living conditions and thereby stimulating support for the family.

Conclusions

With this research, the Information Architecture for Citizen Collaboration in Health matters was developed in the areas of the Pinar del Rio municipality. The results of the analysis and design stages of the information management software have been presented. In each stage, the required documentation has been prepared according to the development methodology, in addition, the implementation of the application prototype, as a conclusion of the design stage and its analysis. This software motivates the need to streamline, improve, adapt, socialize and reduce costs of the processes and/or activities of the public system and create channels that allow increasing citizen participation.

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Substance Abuse and Poor Sleep Among Adolescents: A Mind Genomics Cartography

DOI: 10.31038/PSYJ.2024652

Abstract

Ninety-nine young respondents evaluated different combinations of messages about the effects of substance abuse and sleep issues. The test stimuli were messages developed by generative AI (ChatGPT 3.5). The research followed the process established by the emerging science of Mind Genomics. The study investigated four elements (messages) each about four topics related to drug use: dangers and negative consequences, health alternatives to drug use, in depth consequences when one uses drugs, how poor sleep affects mood, energy levels, and ability to focus. The 16 elements were combined by experimental design, the specific combinations of elements (messages) differing for all respondents. The rating was “Describes Me.” Analysis by ordinary least squares regression showed that no single message strongly applied to the entire panel of 99 respondents. Clustering to generate three mind-sets showed three distinct groups, easy-to-interpret response patterns. These are Leisure Enthusiasts who do not respond to the negative elements (n=44), Serious Behavioral Problems (n=31), and Emotion Issues with Impaired Judgment (n=24). AI summarized the mind-sets clearly at two levels, first in terms of strong messages and suggestions for new ideas, and then at a more global level. The paper shows the feasibility of creating databases of the mind at low cost, within a day, with powerful insights and direction for communication emerging from the process.

Keywords

Adolescent sleep issues, Adolescent substance abuse, Generative AI, Mind genomics

Introduction

The growing problem of drug use leading to sleep disorders among adolescents is becoming increasingly relevant to medicine specifically, but to society in general. According to current research, misuse of drugs made for children and adults may, in some cases, negatively affect sleep patterns, leading to a variety of health problems and cognitive deficits [1-3]. A conventional approach by practitioners provides targeted treatments and therapies to address both the drug misuse problem and the sleep disorders, considered as two different indications. Problems frequently occur when teenagers resist therapy or do not cooperate with prescribed measures, either or both making it difficult for healthcare professionals to effectively address the problem. The result is that adolescents suffering from drug use and sleep issues may express themselves in a number of ways, using language indicative of bewilderment, frustration, and pessimism. Emerging societal difficulties associated with drug use that cause sleep problems in teens include increasing rates of scholastic underachievement, social isolation, and mental health illnesses. In turn, parents of these adolescents may report feelings of shame, powerlessness, and concern for their child’s well-being, exacerbating the issue [4-6].

Parents may go to considerable measures to address this issue— these include obtaining help from mental health specialists, attending therapy sessions with their child, and adopting tougher regulations and monitoring to handle substance addiction and sleep problems. However, the complexities of drug use and sleep issues in teens coupled with other behavioral issues involved in maturation make long-term remedies hard to achieve [7,8]. When addressing the growing problem of drug use resulting in sleep disorders among teenagers, a key issue is how drug use affects the brain and interrupts young people’s normal sleep habits. Adolescent sleep patterns may also be influenced by external variables such as drug usage, which can cause increased anxiety, restlessness, and interrupted sleep cycles, as well as the social determinant of drug use. Certain medicines such as stimulants and depressants have been reported to interfere with the synthesis of neurotransmitters which govern sleep, making it harder to fall and remain asleep. Other factors to consider which lead to teenage drug use are social and environmental situations. For example, peer pressure, stress, and a lack of parental monitoring may all contribute to young people commencing and continuing drug misuse habits [9].

Helping the Young Medical Professional to Understand the Adolescent Mind

Medical professionals play a vital role in understanding the minds of their adolescent patients, especially when it comes to identifying and addressing substance abuse issues. Experience can be a valuable asset in this regard. Seasoned doctors may have encountered a wider range of cases and developed a deeper understanding of adolescent behavior and mental health. However, not all doctors have extensive experience with adolescent patients [10,11]. One standard way to learn about a patient’s mind is to use questionnaires. At the time of this writing, fall of 2024, the practice of surveys is well-established in many domains, whether medical, commercial, and even recreational. The interested professional focuses on the topic and attempts to generate a set of questions about that topic, with these questions requiring simple answers. The common practice is to present these surveys, either or person, or more frequently on the internet. The survey-taker, known as the respondent, completes the questionnaire [12].

Questionnaires are powerful tools to gather information about adolescent patients, their experiences with substance abuse, as well as their sleep problems. By asking targeted questions about drug use, sleep patterns, and related behaviors, medical professionals can gain a better understanding of the factors contributing to these issues. Various questionnaires have been developed for use with teens, providing valuable data that can inform treatment plans and interventions aimed at addressing substance abuse and sleep disturbances in young people.One of the interesting sidebars of the “survey business” is the biases that the survey creator, viz., the “researcher” encounters. Biases range from non-response (refused to participate) to indifferent (assigned random responses), and all too often attempt to “outsmart” the researcher by guessing what are appropriate, socially acceptable answers, rather than real answers [13].

Creating a system that allows medical professionals to understand the minds of adolescents poses a significant challenge when the doctor lacks experience or the patient is non-communicative. Traditional methods of patient assessment may not always be effective with younger populations, who may struggle to express their thoughts and feelings verbally. In such cases, innovative approaches—such as using targeted questionnaires or assessments specifically designed for teens—could offer valuable insights into substance abuse and sleep-related issues. One metaphor for understanding the minds of adolescent patients is the concept of taking a patient’s blood at the start of the patient-doctor interaction. Just as a blood test can provide valuable insights into a patient’s physical health, a metaphorical “phlebotomy of the mind” could help medical professionals assess the mental and emotional well-being of their adolescent patients. By developing a systematic approach to understanding the minds of young people, doctors may be better equipped to address issues such as drug use and sleep problems [2,14,15].

The Mind Genomics Set up Process — AI Generated/ Human Edited Questions and Answers, Human Generated Classification and Rating Scale

An alternative approach to asking single, disconnected questions about a topic is to present people with combinations of ideas or messages, and instruct these respondents (viz., our survey-takers) to read the combination and to rate the entire combination. Furthermore, these combinations are comprised of single messages, simple phrases, seemingly thrown together in a haphazard manner, although later we will show that this seemingly haphazard manner is far from the case. The combinations are structured according to an underlying experimental design [16]. The task is rather easy, although boring. The respondent sits in front of a computer screen. The respondent sees combinations of messages emerge. The respondent simply rates the combination. The average person simply goes through these combinations in almost an indifferent fashion, feeling like some how they are guessing. The reality is that there is an underlying structure, the ratings make sense, and the results show how people think.

The process presents people with ordinary “slices of life” created in a way that the respondent cannot “game the system.” Rather, after a moment of surprise, most respondents sit down and do the task. The respondent ends up “grazing”, looking at the vignette and then assign a rating. The system invokes what the late Nobel economist called System 1 thinking, where the responses are virtually automatic. The process works very well with motivated as well as unmotivated respondents. There is no requirement that the respondent think about the topic. Rather, it suffices that the respondent pays some attention to the material, and not just type the same answer again and again [17]. Mind Genomics requires four questions and four answers to each question. If that is done, the rest of the exercise is simple. But how does the researcher come up with these questions? The early history of Mind Genomics revealed a major block to the successful use of the approach. Many people, including professionals, ended up ‘freezing’ when instructed to provide four questions. It was simple enough to name the study, but the creation of questions posed problems— generally emotional ones. As an example, consider Figure 1: Panel A shows the screen as presented to the user. Figure 1, Panel B shows a completed screen. Often the requirement to create a set of four questions which “tells a story” becomes a daunting task, an obstacle to be overcome in the research process [18,19].

Figure 1: Panel A shows the screen as presented to the user. Panel B shows a completed screen

Recent enhancement of the Mind Genomics platform has incorporated AI in the form of LLM, large language models (here ChatGPT 3.5). The access to the AI is by means of Idea Coach, a small rectangle in which the user can type the request. Table 1 (top) shows the query as provided to the AI, and Table 1B shows the 15 questions generated from this first iteration. The query is simple, stressing simplicity and understandability. Once the user is satisfied with a question, it is a simple matter to select that question. The selection of a question results in the insertion of the question into the study. When the question has been selected, it is straightforward for the researcher to edit the question, polishing and formatting it so that the subsequent AI effort to “answer” this question will generate meaningful answers, rather than just questions which end up with yes/no answers. The same process is used to select four answers for each question. Idea Coach maintains the selected questions, allowing the user to iterate to find answers and then polish them before inserting the answers into the template [20,21].

In the use of the LLM, the questions and answers usually require some editing. The questions should be edited to encourage expansive answers, using words like “explain in detail”. This embellishment is important because the AI will use the questions themselves to drive the creation of answers. The research requires answers which paint a word picture. The only way to get those answers painting a word picture is to instruct the AI to “explain” or “embellish,” or “describe how”. These are words which generate meaningful phrases painting the word picture.

The next step creates the self-profiling classification questionnaire which enables the researcher to gain more information about the respondent. Two questions are automatically asked—age and gender. The researcher can ask up to eight additional self-profiling questions, each with a possible eight answers. Table 2 shows the self-profiling classification created specifically for this study by the researcher.

Table 1: The instruction to AI to create the questions (top), and the 15 questions created in this iteration.

Table 2: The self-profiling questions and answers, completed at the start of the evaluation, before any vignettes are rated.

Creating Vignettes by Combining “Elements” (Answers)

Table 3 shows the four questions generated by the combination of the human researchers and AI. Under each question are the four answers. Each edited/polished question generated 15 answers. The researcher selected four answers, inserting the answers into the study after polishing them. As a consequence, the questions and answers in Table 4 are usually better than what would be generated even by an experienced professional. The user can run many iterations for questions and for answers, as well as polishing them to make them more precise.

Table 3: The “raw” material, comprising questions and answers

If this study was run as a typical study, then each of the 16 elements (A1-D4) would be presented as a single question, and the respondent (survey-taker) would evaluate each element independently. Of course, the researcher would randomize the order of the elements to reduce order bias. The biggest problem of these one-at-a-time evaluations is that they have no context—or at least the context may change depending upon the element.

The Experimental Design Underlying the Construction of the Vignettes

A better way might be to create combinations of these elements, doing so in a structured manner, so that the combinations, the vignettes, tell a story, albeit a story which has few connectives. Figure 2 shows an example of what the respondent might see.

Figure 2: Example of what the respondent might see

Figure 2 looks disconnected but the respondent evaluating the vignette ends up with a sense of what is being communicated. After evaluating the first two or so vignettes, most respondents stop fidgeting and simply look at the vignette, and rate it on the scale shown in Table 4. It is important to note that Figure 1 does not attempt to present a polished paragraph to the respondent, one which reads well, with all the connectives. Although one might be tempted to “pretty up” the vignette, the reality is that the respondent has an easier time “grazing through” the sparse structure presented by the vignette. Less effort is required to identify the information in the vignette, and consequently the respondent can quickly evaluate each vignette. The happy consequence is that the respondent can go through the 24 vignettes quite quickly without incurring much fatigue.

The vignette is rated by the respondent on a simple 5-point scale shown in Table 4. The scale has two sides. The left side, the first part read, has the respondent decide whether the description in the vignette describes or does not describe them. The right-hand side has the respondent decide whether the description is typical or not typical. The rating question captures two aspects of the vignette, fit to the person, and typicality of the statements. These are not explained to the respondents. Most respondents end up having an intuitive sense of what the rating scale means. Their answers suggest that this intuitive sense of its meaning operates in the interview, as we will see below.

Table 4: Five-point rating scale

Experimental Design to Create Vignettes Which Represent “Slices of Life”

The Mind Genomics effort allows exploratory research rather than requiring confirmatory research. As such, the studies need not be based on theory, with the goal of confirming or disconfirming a hypothesis. Rather, the Mind Genomics studies end up encouraging exploration, intuition, and iteration. It is easy to react to combinations of messages, vignettes. We do it all day long, as we react at an almost automatic level to the world around us. Rather than asking ourselves “what is important about this vignette” or this particular situation, a task requiring thought, we simply react to what is around us. In colloquial terms we “go with the flow”.

By presenting respondents with combinations of messages, i.e., mixture of messages such as the answers (elements) shown in Table 3, we put the respondent into a more natural situation, one which resembles daily experience. All the respondent has to do is react. The structure of the vignette allows the researcher to present slices of life to the respondent, have the respondent rate the combinations of these slices of life, and when done, properly enables the researcher to numerically estimate the driving power of each of the 16 elements, even when the respondent themselves cannot do so. The experimental design will enable us to determine the degree to which each of the 16 elements fits the respondent. The key to success here is to present the “right” combinations of elements, the “right” slices of life.

The experimental design for Mind Genomics comprises one basic specified set of combinations, which is permitted into several hundred variations. Each variation differs in the specific combinations, but the mathematical structure is maintained, and the design is tested to ensure that it runs in the statistical analysis.

  1. The design requires four questions (aka categories, silos), each question associated with four answers (aka messages, elements).
  2. The underlying experimental design creates 24 combinations or vignettes.
  3. Each vignette has a minimum of two elements and a maximum of four elements.
  4. Each element appears equally often, meaning that it appears five times in the set of 24 questions and is absent 19 times.
  5. The experimental design lays out the structure of each of the 24 vignettes. Some vignettes will have only two elements. Some vignettes will have three Most vignettes will have four elements.
  6. The absence of elements in a vignette means that the combinations of these vignettes are incomplete. That incompleteness is deliberate. It allows the researcher to estimate the contribution of each of the 16 elements to the rating because there are situations where the element is missing. This is important for regression analysis, specifically dummy variable regression analysis,
  7. Up to now, we have created a set of 24 combinations for one respondent with the property that each question can contribute at most one element (answer) to a vignette, sometimes contributing no answer to the vignette, but never contributing two answers to the This is important for statistics and also ensures that the vignette will not present mutually contradictory messages.
  8. The 16 elements are statistically independent of each other.
  9. The final benefit or the final piece of information is that all of these vignettes, these combinations form one experimental design.
  10. The final task is to permute the design. We keep the basic structure of the design, but we change the specific combinations by changing the element numbers. For instance, A1 may become A3, A2 may become A1, A3 may become A2, and A4 may remain as This permutation must be checked to make sure that the elements remain statistically independent of each other. The result is several hundred permuted designs.
  11. Every respondent is presented with a different set of 24 combinations, although the mathematical structure remains the The practical benefit is that the researcher need not know anything coming into the study. The researcher need not know the correct combinations because the system itself will take care of it.
  12. To sum up, the underlying experimental design ensures that the researcher can understand how people respond to ideas, by forcing them to respondent to combinations, the vignettes, the aforementioned “slices of life.” Through statistics, specifically OLS (ordinary least squares) regression used by Mind Genomics, the driving power of each element emerges immediately in a way that cannot be “gamed.”

Fielding the Study with a Panel Provider (Or with One’s Own Patients)

Once those bookkeeping steps are done, the user contacts the panel provider—in this case Lucid Inc., a panel aggregator with access to tens of millions of people around the world. The actual panelists are the appropriate group, adolescents, who have agreed to participate in these studies. They receive rewards. To the authors, these respondents, these survey-takers, are totally anonymized. We have no idea who they are, no idea the reward that they get. Typically, to run 99 people as respondents requires approximately an hour or two from the time the email invitation is mailed out until the respondents complete the 3–4-minute survey There is a tremendous benefit of having a panel of paid, motivated people. Otherwise, it might take weeks and months to get the same number of respondents.

The panel provider is contacted, and the request is made for a specific age group, market, etc. The age range requested was 15 to 21 years old. No two respondents evaluated the same set of combinations. The result is that the study allowed us to explore a wide variety of combinations. As noted above, a key benefit is that there is no need to know the topic at the start of the project.

Transforming the Data and Creating Models Relating Elements to the Newly Transformed Binary Variable

Each rating generated a rating on the 5-point scale. A rating of 1, 2 or 3 was converted to 0. A rating of 4 or 5 was converted to 100. A vanishingly small random number was added to each newly created binary variable, the aforementioned 0 or 100. The reason for that is purely prophylactic. With the vanishingly small random number (<10- 2), one does not influence the analysis through ordinary least squares regression, but one guarantees that every one of the respondents will have variability in their newly created binary variables. The analysis is straightforward, whether we do it at the level of a group such as the total panel of 99 respondents, by groups defined by who the respondent claims to be based on the self-profiling classification, or even by individuals.

Recall that the dependent variable, the newly created binary variable, takes on 0 or 100, and each of the 16 elements has the value 0 when absent from the vignette, and 1 when present in the vignette. We create a simple equation of the form listed below:

Dependent variable= k1A1 + k2A2 + k3A3… k16D4. The magnitudes of the coefficients, k1 – k16, tells us the degree to which the appearance of the element in a vignette drive the respondent to say, “that is me.”

Recall that our respondents were just sitting there being exposed to a variety of messages embedded or combined in these vignettes. They had no idea what was going on. It was a “blooming, buzzing confusion” to them, in the words of Harvard psychologist William James. But throughout the effort, the respondents just simply sat there, grazed, as we said, through the vignettes, and assigned a number. Most of the adolescents, had we asked them, would have said they were guessing and would shrug their shoulders.

Table 5 shows the coefficients. The coefficients show the degree to which the element is perceived as saying “this is me.” We can consider the coefficients as conditional percentages. Thus, a coefficient of 10 means that 10% of the answers would be “that describes me”, were the element to be put into the vignette. From many of these studies, it would appear that a coefficient around 20 would be considered statistically significant. The rationale for this number is that the coefficients estimated with an additive constant show that a coefficient around 10 is statistically significant based upon a simple T test of coefficients. A model without an additive constant would show that same value of 10 to be 20. Thus, we create a simple operational rule that we should look for high coefficients of 21 or higher in models estimated without an additive constant, viz., models that are said to go through the origin.

With the following in mind, Table 5 suggests that no elements can be said to read our operational criterion of 21 or higher.

Table 5: Coefficients for the total panel for each of the 16 elements. Coefficients of 21 or higher denote very strong performing elements. The elements are presented in descending order of magnitude for each question.

Mind-Sets: Moving to ‘Deducing how a Person Thinks’ by the Pattern of the Coefficients

Individuals vary in their preferences, coping mechanisms, and interactions with medical professionals. We are also aware that individuals may or may not be capable of identifying what they consider to be essential. With the aid of Mind Genomics, researchers are able to comprehend emergent groups of individuals whose decision-making processes adhere to distinct sets of criteria. Mind Genomics enables the researcher to identify different mind-sets. Mind-sets are defined as people thinking the same way about a topic. The important contribution of Mind Genomics is its ability to create these mind-sets at the level of the granular, at the level of the problem and its specificities. By having a bottom-up approach, one can create mind-sets for any specific problem, such as the one we are dealing with right now. One does not need mental gymnastics to translate macro mind-sets to specific topics, an issue often calling for creative re-thinking, with the mind-set data reworked and analyzed to produce an answer for a specific granular problem.

To create the mind-sets, one uses k-means clustering, a well- recognized statistical approach [22]. In our specific case of 16 elements, each respondent has 16 coefficients. We compute the distance between all pairs of the 99 respondents—a simple statistic. That statistic is called D, for distance, and is defined as (1 – Pearson correlation). The Pearson correlation quantifies the strength of the linear relation between two sets of data. A Pearson correlation of +1 means a perfect linear relation, whereas a Pearson correlation of -1 means a perfect inverse relation. Respondents with high values of D, near 2 are always in the same mind-set or cluster. Respondents with low values of D near 0 are generally in different mind-sets or clusters.

Once the respondents are assigned to either two clusters or mind- sets or separately three clusters or mind-sets, it is simple to create new groups for OLS regression, which we saw above for the Total Panel in Table 6. This time we run five regressions, first for the two mind-sets, and then for the three mind-sets.

Table 6 shows us the coefficients for the two mind-sets and then for the three mind-sets. The sum of the number of respondents is always 99. Each respondent fits into only one of the three mind- sets. There are empty cells in Table 6, corresponding to the elements whose coefficients are 5 or lower. Finally, Table 6 is sorted by the mind-sets, with all elements failing to score strongly in at least of the mind-sets put at the bottom of the Table. The mind-sets for the three- cluster segmentation by k-means make intuitive sense. The mind- sets are coherent, even though the entire analysis was done strictly by mathematical principles without any appeal whatsoever to the meaning of the elements. The mind-sets emerge quite clearly.

Table 6: How the elements performed when the 99 respondents were separately divided into two mind-sets, and then into three mind-sets respectively. Strong performing coefficients of 21 or higher are shaded. The table is sorted by the coefficients for the three mind-sets to highlight the differences among the mind-sets.

Table 7 shows the distribution of the selected answers for the three mind-sets, and for total panel. The distribution of the self-profiling answers by mind-set is unclear, in contrast to the clarity emerging from strong performing elements for each mind-set. There are some differences among the mind-sets, but the patterns are hard to discern, even though one might have expected to see more pronounced differences among the segments. It is this interpretability of mind-sets based upon very strong performing elements which enables Mind Genomics to create easy-to-understand “new knowledge.”

Table 7: The distribution of answers by mind-set and total for the self-profiling classification

Putting AI to the Task of Adding Insights to the Mind-Sets

The last part of our analytics from the study itself is the interpretation of the findings through artificial intelligence. The automated re-analysis looks at the results from each mind-set, considering only those elements in the mind-set which generated a coefficient of 21 or higher. Through generative AI (ChatGPT 3.5) the AI answers a fixed set of questions as shown in Table 8. The results for each mind-set and to answer a variety of prompts. AI looks only at the strong performing elements, previously defined as elements which have coefficients of 21 or higher. Therefore, if a mind-set does not have any elements of 21 or higher, it does not appear in this AI analysis.

Table 8 shows the analysis. The prompts shown in Table 8 give a sense of some of the deeper information and insights that might emerge from the data. We might characterize the material in Table 8 as preliminary material for additional insights. Or, to take a phrase from the late Professor of Computer Science at Havard University, Anthony Gervin Oettinger, the material in Table 6 could be considered TACT, Technical Aids to Creative Thought [23].

Table 8: AI summarization and deeper analysis of the strong performing elements for each of the three mind-sets

Instructing AI to Provide a Simple Overview

Final analysis is based on the need to simplify the results. We can take all of the information provided by AI detailed analysis in Table 8 and summarize it through one simple query as shown in Table 9. The artificial intelligence does a very good job of taking the material that it itself has generated and summarizing it. The bottom of Table 9 shows the summarization in terms of what the mind-sets are, in what aspects they differ, and what innovations can AI suggest. The important thing here is that we can have artificial intelligence summarize and summarize more. Here is a situation where less is more.

Table 9: AI summarization of the results previously presented in Table 8

Discussion and Conclusions

Mind Genomics studies offer a unique approach to understanding human behavior and decision-making, unlike traditional questionnaires. By presenting respondents with descriptions and scenarios, researchers can tap into their instinctual responses and emotions, providing a more accurate representation of their feelings about a topic or product. This method often involves experiments where participants are presented with varying descriptions or messages, making it difficult for them to guess the “right” answer. This allows researchers to capture genuine gut-level reactions, revealing hidden insights that may not be apparent through traditional questioning methods.

Mind Genomics studies offer a practical and efficient way to gather data, as they focus on individuals’ reactions to descriptions or messages, allowing researchers to quickly compile large databases of knowledge. Dividing people into groups based on their responses to different messages and descriptions allows for a deeper understanding of how individuals process information and make decisions. By identifying patterns in how different groups respond, researchers can tailor messaging and communication strategies to better reach and engage specific audiences.

The study presented here is an example of the effort put in versus the output emerging. The time to create the questionnaires can be measured in hours, certainly less than half a day. The time to set up the study itself and launch was another hour or two. The time to obtain the fully analyzed data was an hour or two, with the fully analyzed data emerging in the form of a user-friendly Excel file. Finally, the time to summarize the data a second time through AI was less than an hour. Altogether, the project could have been completed within 24 hours. The time to write the paper is, of course, longer, at least for the current iteration of Mind Genomics, but that time will “collapse” in future iterations.

Acknowledgment

The authors would like to thank Vanessa Marie B. Arcenas, Angela Louise C. Aton, and Isabelle Porat for helping to produce this manuscript.

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Crimean-Congo Hemorrhagic Fever DNA Aptamers Inhibit Plaque Formation In Vitro

DOI: 10.31038/IDT.2024522

Abstract

The top five candidate DNA aptamer sequences developed and published previously by Bruno et al. (BMC Research Notes 5: 633, 2012) against Crimean- Congo Hemorrhagic Fever virus envelope glycoprotein precursor peptides were screened for plaque reduction activity against viable CCHF Oman virus in a BSL-4 laboratory. Statistically significant reductions in plaque forming unit (pfu) counts for CCHF using SW-13 cell cultures were obtained when pretreated with these aptamer DNA sequences which demonstrated much greater efficacy versus a polyadenine 49mer control oligonucleotide at the same concentrations.

Keywords

Aptamer, Crimean-Congo hemorrhagic fever, Glycoprotein, Plaque, Virus

Introduction

Passive immunity for lethal hemorrhagic viruses such as Ebola has been demonstrated using convalescent antiserum [1-4]. Similarly, humanized monoclonal antibodies produced by Eli Lilly and Regeneron proved effective as passive immunity agents to protect patients suffering severe COVID during the pandemic [5].

Unfortunately, convalescent human antisera and humanized monoclonal antibodies are difficult and rather expensive to develop and mass produce. Nucleic acid aptamers present a much less expensive and more facile development alternative to humanized antibodies for industrial scale up of biologics to bind and block or inhibit progression of deadly viruses. A number of successful in vitro experiments exist reporting reductions in the number plaque forming units (pfu) or blockage of infections when viruses are pretreated with specific cognate aptamers and then added to cultures of mammalian host cells [6-9].

Crimean-Congo Hemorrhagic Fever (CCHF) virus is a widespread tick-borne virus member of the Nairoviridae with mortality reported as high as 30% in affected humans primarily across Europe and Africa [10]. As such, this virus is the subject of intense research [10-13]. While small molecule viral inhibitors have demonstrated significant efficacy against CCHF [12], humanized monoclonal antibodies are a prime target for the development of therapeutic medical countermeasures as well [10,13]. Human antibodies are known to synergistically neutralize the virus when bound to the envelope glycoprotein precursor [10]. In this work, one of the top 5 aptamers was shown to cause up to a 92.2% reduction in plaque forming units (pfu) and the other four aptamer DNA sequences also appear to exhibit significant efficacy as passive immunity pretreatment agents at least thus far in vitro.

Materials and Methods

Aptamer Development and DNA Sequencing

The SELEX aptamer development process against synthetic peptides derived from the CCHF envelope glycoprotein precursor (GenBank AHL45281.1) attached to magnetic microbeads was previously described by Bruno et al. [14]. All DNA aptamers or control oligonucleotides were synthesized by Integrated DNA Technologies (Coralville, IA).

SW-13 Plaque Reduction Assay

The traditional pfu reduction assay did not work well with Vero cells in initial experiments for unknown reasons. Therefore, the method of Paragas et al. [11] was used with human SW-13 adrenal cortex epithelial cells (ATCC CCL-105) except that crystal violet dye was used instead of neutral red. SW-13 cells were cultured in the BSL- 4 4 laboratory of the Texas Biomedical Research Institute (TBRI; San Antonio, TX, USA) to a confluent monolayer in Dulbecco’s minimum essential medium (DMEM) plus 10% fetal calf serum (FCS) in 6-well plates at 37˚C with 5% CO2. The culture medium was replaced with a 1:2,500 dilution of stock CCHF Oman strain in 0.5 ml of DMEM plus 2% FCS with or without the aptamer levels indicated in the figures (0 to 1,900 nanomoles of aptamers) for 60 min at 37˚C with gentle rocking. Culture medium was removed from the wells and 5 ml of DMEM plus 1% penicillin-streptomycin-L-glutamine mixture and 16% methylcellulose overlay was added to each well. Thereafter, 6-well plates were incubated in a humidified incubator at 37° with 5% CO2 for 7-8 days. At the end of this week-long incubation period, the DMEM and methylcellulose overlays were removed and 5 ml of room temperature 10% neutral buffered formalin was added to each well as a fixative. Plates were refrigerated between 2°C to 8°C overnight (12 h minimum). The following day, the formalin was removed and wells were washed with Phosphate Buffered Saline (PBS). Plaque counts were performed manually by two technicians in agreement about the numbers of pfus following staining of each well in 1 ml of crystal violet, followed by removal of the dye, a gentle rinse with fresh tap water and air drying. Plaque counts were subjected to ANOVA statistical testing and found to show statistically significant differences for all of the aptamer-pretreated groups versus the blanks and ploy-A controls with p values <0.01.

Results

Figure 1 shows the results of initial plaque reduction studies in which the means of triplicate well readings with 2X standard deviation bars appeared to produce a >50% reduction in the mean number of pfu per well from pretreatment of the Oman CCHF virus with 47 nmoles of aptamer 2 versus the >120 pfu for the blank control without any aptamer pretreatment additive. The blank in this initial experiment was comparable in number of pfu versus the poly-A 49mer control wells. The other aptamers in this first experiment did not reduce plaque formation >50%, but also demonstrated statistically significant reductions in plaque formation.

Figure 1: Initial plaque reduction screening experimental results for the top 5 aptamers and a poly-adenine 49mer all at 47 nmole of DNA per well except for the zero aptamer added blank. The averages and 2X standard deviation bars for 3 measurements are shown for each group.

In the second set of higher dose studies (Figure 2) with only aptamers 1 and 2, the aptamers exhibited a >90% reduction (up to 92.2% for aptamer 1 at 1,900 nmoles of aptamer) which was dose- dependent. Although the poly-A control exhibited some dose- dependent reduction in plaque formation as well in Figure 2, it was not nearly as effective at plaque reduction versus the more specific CCHF aptamers (~50% reduction versus >90%) at the 1,900 nmole concentration level.

Figure 2: Dose-dependence plaque reduction results for aptamers 1 and 2 versus the poly-A 49mer and the blank group at the higher DNA concentrations indicated. The averages and 2X standard deviation bars for 3 measurements are shown for each group.

Discussion

Jalali et al. developed numerous aptamers against the conserved internal nucleoprotein (NP) of CCHF which produced excellent reagents for sensitive detection [15] of many different variants of lysed CCHF viruses. However, anti-NP aptamers are not very useful as therapeutics or prophylactics for passive immunity since they do not bind the viral surface or prevent viral fusion with the host cell [6]. Here the author describes the first in vitro testing of aptamers developed against the CCHF envelope glycoprotein precursor complex [14] which could inhibit or prevent CCHF viral fusion and host cell entry as demonstrated by the present data (Figures 1 and 2). The top 5 aptamer DNA sequences reported here (Table 1) were mostly generated against synthetic peptides in the Gc region of the CCHF envelope glycoprotein precursor [14] (amino acids 1041 through 1684) which form spikes on the viral surface involved in viral host cell entry [16]. The author has previously reported 3-D molecular models of the top 5 aptamers docked with the CCHF envelope glycoprotein precursor [17] which bear some resemblance to the precursor domain II regions bound by the antibodies Mishra et al. have reported [10] making the results reported here quite plausible.

Table 1: Aptamer DNA sequences.

Aptamer No.

DNA Sequence 5’-3’

1

ACA GTT AGA GCT TGC CGT ATG CCT TTG TTA ACA TAA

2

ACT AAC CGA ATG GCA GTT TCC CCC TTA TCC ATC TAT

3

GGG ATA GGG TCT CGT GCT AGA TG

4

CGC TGA AGC AAG ACA TTA TCG GGA CAT TGC CGT GA

5

TGA CAC GCG TAC GGG TCC GGA CAT GTC ATA ACG GAC

Conclusions

In this preliminary in vitro study, the top 5 aptamer candidates from Bruno et al.’s previous publication [14] demonstrated solid in vitro potential to act as passive immunity biologics. CCHF aptamers 1 and 2 in particular demonstrated strong dose dependence in vitro with >90% efficacy at the 1,900 nmole dose and deserve further research attention as possible alternatives to antibodies for the passive therapy of CCHF. The biggest issues with using aptamers in vivo is their small size making them subject to rapid kidney clearance and susceptibility to serum nucleases. However, aptamer pharmacokinetics can be greatly enhanced by covalent addition of heavier inert blocking agents such as polyethylene glycol or some proteins to the 3’ end [18-20].

Acknowledgments

Funding was provided by a U.S. Defense Department SBIR Contract No. W911SR22P0007. The author thanks Dr. Ricardo Carrion and Dr. Michal Gazi of the Texas Biomedical Research Institute (TBRI) in San Antonio, TX for maintaining the SW13 host cell cultures and conducting plaque assays in the BSL-4 laboratory.

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