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• 21. [Article] The impact of Oregon’s Coordinated Care Organizations on Prenatal Care Access and Quality : A Difference-in-Differences Analysis

  Background: Prenatal care (PNC) is an important preventive health service that can influence the health of the four million women who give birth annually in the United States, and the health their infants. ...

  Citation × Citation Citation Abstract Copy Title: The impact of Oregon’s Coordinated Care Organizations on Prenatal Care Access and Quality : A Difference-in-Differences Analysis Author: Muoto, Ifeoma O. Background: Prenatal care (PNC) is an important preventive health service that can influence the health of the four million women who give birth annually in the United States, and the health their infants. Despite efforts to increase women’s access to PNC services, significant disparities in PNC utilization and maternal/child health outcomes by insurance type and race/ethnicity persist in the United States. The past decade has witnessed several major health reforms at both national and state levels. However, the impact of these reforms on the quality of PNC, and on disparities in PNC utilization is not known. In 2012, the state of Oregon established Coordinated Care Organizations (CCOs) as comprehensive providers of care for Oregon’s Medicaid beneficiaries. CCOs are characterized by a global budget payment mechanism and financial incentives for high quality care. Timely initiation of PNC – which has been associated with improved maternal and infant health and utilization outcomes – is one of seventeen quality metrics for which CCOs can receive incentive payments. Objectives: The first objective of the current study was to estimate the impact of CCO implementation on the probability of initiating PNC in the first trimester, and on PNC adequacy among Oregon Medicaid beneficiaries. The second objective of the study was to determine if the implementation of CCOs influenced disparities in PNC utilization between Medicaid and privately-insured women, and between non-Hispanic White women and Hispanic/non-Hispanic Black women. Study Design: This quasi-experimental retrospective observational study drew from two data sources: Oregon Vital Records (Birth Certificate statistical files) from the department of Health Analytics of the Oregon state public health department and Washington State’s Linked Birth- CHARS (Comprehensive Hospital Abstract Reporting System) data from the Washington State department of health. A difference-in-differences approach examined PNC utilization before and after CCO implementation. Washington State served as the control group, as its Medicaid financing and delivery systems remained unchanged. Multivariable linear probability analysis was used to control for confounding factors, including maternal age, race/ethnicity, education, parity, marital status, smoking history, previous preterm birth, and maternal morbidity. Population Studied: All births in Oregon and Washington from 2008 – 2013, which were covered by either Medicaid or private insurance, were included in the analysis. Since CCOs started operating mid-year in 2012, June through December 2012 was considered a transition period and births during this period were excluded from the analysis. Principal Findings: CCO implementation was associated with a significant increase in the probability of PNC initiation in the first trimester and a reduction in insurance-type disparities in first trimester PNC initiation and PNC adequacy among Oregon Medicaid beneficiaries. Racial/ethnic disparities did not change following CCO implementation. Conclusions: The implementation of CCOs in Oregon had a positive impact on the timeliness of PNC initiation among Medicaid beneficiaries, and also reduced disparities in PNC quality between Medicaid and privately-insured women. Implications for Policy or Practice: The ongoing health system transformation in Oregon provides an ideal setting to assess the impact of a novel health service delivery model on PNC utilization. If Oregon is successful in this bold and unprecedented move, it could serve as a model for other Medicaid and commercial health plans seeking to improve PNC quality. Further study on the longer-term effects of CCO implementation on PNC quality as well as the effect of CCOs on other health care domains, is warranted. Title: The impact of Oregon’s Coordinated Care Organizations on Prenatal Care Access and Quality : A Difference-in-Differences Analysis Author: Muoto, Ifeoma O. Background: Prenatal care (PNC) is an important preventive health service that can influence the health of the four million women who give birth annually in the United States, and the health their infants. Despite efforts to increase women’s access to PNC services, significant disparities in PNC utilization and maternal/child health outcomes by insurance type and race/ethnicity persist in the United States. The past decade has witnessed several major health reforms at both national and state levels. However, the impact of these reforms on the quality of PNC, and on disparities in PNC utilization is not known. In 2012, the state of Oregon established Coordinated Care Organizations (CCOs) as comprehensive providers of care for Oregon’s Medicaid beneficiaries. CCOs are characterized by a global budget payment mechanism and financial incentives for high quality care. Timely initiation of PNC – which has been associated with improved maternal and infant health and utilization outcomes – is one of seventeen quality metrics for which CCOs can receive incentive payments. Objectives: The first objective of the current study was to estimate the impact of CCO implementation on the probability of initiating PNC in the first trimester, and on PNC adequacy among Oregon Medicaid beneficiaries. The second objective of the study was to determine if the implementation of CCOs influenced disparities in PNC utilization between Medicaid and privately-insured women, and between non-Hispanic White women and Hispanic/non-Hispanic Black women. Study Design: This quasi-experimental retrospective observational study drew from two data sources: Oregon Vital Records (Birth Certificate statistical files) from the department of Health Analytics of the Oregon state public health department and Washington State’s Linked Birth- CHARS (Comprehensive Hospital Abstract Reporting System) data from the Washington State department of health. A difference-in-differences approach examined PNC utilization before and after CCO implementation. Washington State served as the control group, as its Medicaid financing and delivery systems remained unchanged. Multivariable linear probability analysis was used to control for confounding factors, including maternal age, race/ethnicity, education, parity, marital status, smoking history, previous preterm birth, and maternal morbidity. Population Studied: All births in Oregon and Washington from 2008 – 2013, which were covered by either Medicaid or private insurance, were included in the analysis. Since CCOs started operating mid-year in 2012, June through December 2012 was considered a transition period and births during this period were excluded from the analysis. Principal Findings: CCO implementation was associated with a significant increase in the probability of PNC initiation in the first trimester and a reduction in insurance-type disparities in first trimester PNC initiation and PNC adequacy among Oregon Medicaid beneficiaries. Racial/ethnic disparities did not change following CCO implementation. Conclusions: The implementation of CCOs in Oregon had a positive impact on the timeliness of PNC initiation among Medicaid beneficiaries, and also reduced disparities in PNC quality between Medicaid and privately-insured women. Implications for Policy or Practice: The ongoing health system transformation in Oregon provides an ideal setting to assess the impact of a novel health service delivery model on PNC utilization. If Oregon is successful in this bold and unprecedented move, it could serve as a model for other Medicaid and commercial health plans seeking to improve PNC quality. Further study on the longer-term effects of CCO implementation on PNC quality as well as the effect of CCOs on other health care domains, is warranted. Close

• 22. [Article] Antimicrobial-Resistant Infections Among Postpartum Women at a Ugandan Referral Hospital

  Introduction Puerperal sepsis causes 10% of maternal deaths in Africa, but prospective studies on incidence, microbiology and antimicrobial resistance are lacking. Methods We performed a prospective cohort ...

  Citation × Citation Citation Abstract Copy Title: Antimicrobial-Resistant Infections Among Postpartum Women at a Ugandan Referral Hospital Author: Bebell, Lisa M., Ngonzi, Joseph, Bazira, Joel, Fajardo, Yarine, Boatin, Adeline A., Siedner, Mark J., Bassett, Ingrid V., Nyehangane, Dan, Nanjebe, Deborah, van Geertruyden, Jean-Pierre, Mwanga-Amumpaire, Juliet, Bangsberg, David R., Riley, Laura E., Boum, Yap, II Year: 2017 Introduction Puerperal sepsis causes 10% of maternal deaths in Africa, but prospective studies on incidence, microbiology and antimicrobial resistance are lacking. Methods We performed a prospective cohort study of 4,231 Ugandan women presenting to a regional referral hospital for delivery or postpartum care, measured vital signs after delivery, performed structured physical exam, symptom questionnaire, and microbiologic evaluation of febrile and hypothermic women. Malaria rapid diagnostic testing, blood and urine cultures were performed aseptically and processed at Epicentre Mbarara Research Centre. Antimicrobial susceptibility and breakpoints were determined using disk diffusion per EUCAST standards. Hospital diagnoses, treatments and outcomes were abstracted from patient charts. Results Mean age was 25 years, 12% were HIV-infected, and 50% had cesarean deliveries. Approximately 5% (205/4176) with ≥1 temperature measurement recorded developed postpartum fever or hypothermia; blood and urine samples were collected from 174 (85%), and 17 others were evaluated clinically. Eighty-four (48%) had at least one confirmed source of infection: 39% (76/193) clinical postpartum endometritis, 14% (25/174) urinary tract infection (UTI), 3% (5/174) bloodstream infection. Another 3% (5/174) had malaria. Overall, 30/174 (17%) had positive blood or urine cultures, and Acinetobacter species were the most common bacteria isolated. Of 25 Gram-negatives isolated, 20 (80%) were multidrug-resistant and cefepime non-susceptible. Conclusions For women in rural Uganda with postpartum fever, we found a high rate of antibiotic resistance among cultured urinary and bloodstream infections, including cephalosporin-resistant Acinetobacter species. Increasing availability of microbiology testing to inform appropriate antibiotic use, development of antimicrobial stewardship programs, and strengthening infection control practices should be high priorities. Title: Antimicrobial-Resistant Infections Among Postpartum Women at a Ugandan Referral Hospital Author: Bebell, Lisa M., Ngonzi, Joseph, Bazira, Joel, Fajardo, Yarine, Boatin, Adeline A., Siedner, Mark J., Bassett, Ingrid V., Nyehangane, Dan, Nanjebe, Deborah, van Geertruyden, Jean-Pierre, Mwanga-Amumpaire, Juliet, Bangsberg, David R., Riley, Laura E., Boum, Yap, II Year: 2017 Introduction Puerperal sepsis causes 10% of maternal deaths in Africa, but prospective studies on incidence, microbiology and antimicrobial resistance are lacking. Methods We performed a prospective cohort study of 4,231 Ugandan women presenting to a regional referral hospital for delivery or postpartum care, measured vital signs after delivery, performed structured physical exam, symptom questionnaire, and microbiologic evaluation of febrile and hypothermic women. Malaria rapid diagnostic testing, blood and urine cultures were performed aseptically and processed at Epicentre Mbarara Research Centre. Antimicrobial susceptibility and breakpoints were determined using disk diffusion per EUCAST standards. Hospital diagnoses, treatments and outcomes were abstracted from patient charts. Results Mean age was 25 years, 12% were HIV-infected, and 50% had cesarean deliveries. Approximately 5% (205/4176) with ≥1 temperature measurement recorded developed postpartum fever or hypothermia; blood and urine samples were collected from 174 (85%), and 17 others were evaluated clinically. Eighty-four (48%) had at least one confirmed source of infection: 39% (76/193) clinical postpartum endometritis, 14% (25/174) urinary tract infection (UTI), 3% (5/174) bloodstream infection. Another 3% (5/174) had malaria. Overall, 30/174 (17%) had positive blood or urine cultures, and Acinetobacter species were the most common bacteria isolated. Of 25 Gram-negatives isolated, 20 (80%) were multidrug-resistant and cefepime non-susceptible. Conclusions For women in rural Uganda with postpartum fever, we found a high rate of antibiotic resistance among cultured urinary and bloodstream infections, including cephalosporin-resistant Acinetobacter species. Increasing availability of microbiology testing to inform appropriate antibiotic use, development of antimicrobial stewardship programs, and strengthening infection control practices should be high priorities. Close

• 23. [Article] Even Start Family Literacy Program : similarities and differences between Hispanic and non-Hispanic participants

  This study used a mixed method approach (quantitative and qualitative) to examine the commonalities and differences between Hispanic and non-Hispanic participants of the Even Start Family Literacy Program. ...

  Citation × Citation Citation Abstract Copy Title: Even Start Family Literacy Program : similarities and differences between Hispanic and non-Hispanic participants Author: Pamulapati, Sireesha This study used a mixed method approach (quantitative and qualitative) to examine the commonalities and differences between Hispanic and non-Hispanic participants of the Even Start Family Literacy Program. Using a life course perspective, this study examined the educational background and life history of Hispanic and non-Hispanic participants, their reasons and goals for program participation, and changes experienced due to Even Start participation. The sample for the qualitative analysis consisted of 32 Hispanic and 25 non-Hispanic female participants. Quantitative latent growth curve analysis was conducted on 96 (75 Hispanic and 21 Non-Hispanic) participants to measure change over time and to estimate the differences in rate of change between Hispanic and non-Hispanic participants. Results of this study indicate that wide commonalities yet vital differences exist between Hispanic and non-Hispanic participants. Poverty was the significant determinant factor in Hispanic as well as non-Hispanic participants' school failure. The experiences and implications of poverty, however, varied for Hispanic and non- Hispanic parents. The reasons and goals for Even Start participation were to achieve self-sufficiency for Hispanic and non-Hispanic parents. Achieving self-sufficiency involved acculturation to the American society for Hispanic participants. For non- Hispanic parents achieving self-sufficiency involved attaining GED and getting off of welfare. No effect of ethnicity was identified on the five outcome measures quantitatively examined in this study, which include knowledge of child development, parenting confidence and support, depression, self-esteem, and life skills. Initial differences existed between Hispanic and non-Hispanic participants in knowledge of child development and life skills, with non-Hispanic participants reporting higher knowledge of child development and greater life skills. Non-Hispanic participants, however, did not make greater gains than their Hispanic participants after being in the program. Qualitative results indicate that skills gained by Hispanic participants helped them acculturate in the American society, whereas for non-Hispanic participants the program helped achieve a sense of purpose and direction in life and create a better life for themselves and their family. Title: Even Start Family Literacy Program : similarities and differences between Hispanic and non-Hispanic participants Author: Pamulapati, Sireesha This study used a mixed method approach (quantitative and qualitative) to examine the commonalities and differences between Hispanic and non-Hispanic participants of the Even Start Family Literacy Program. Using a life course perspective, this study examined the educational background and life history of Hispanic and non-Hispanic participants, their reasons and goals for program participation, and changes experienced due to Even Start participation. The sample for the qualitative analysis consisted of 32 Hispanic and 25 non-Hispanic female participants. Quantitative latent growth curve analysis was conducted on 96 (75 Hispanic and 21 Non-Hispanic) participants to measure change over time and to estimate the differences in rate of change between Hispanic and non-Hispanic participants. Results of this study indicate that wide commonalities yet vital differences exist between Hispanic and non-Hispanic participants. Poverty was the significant determinant factor in Hispanic as well as non-Hispanic participants' school failure. The experiences and implications of poverty, however, varied for Hispanic and non- Hispanic parents. The reasons and goals for Even Start participation were to achieve self-sufficiency for Hispanic and non-Hispanic parents. Achieving self-sufficiency involved acculturation to the American society for Hispanic participants. For non- Hispanic parents achieving self-sufficiency involved attaining GED and getting off of welfare. No effect of ethnicity was identified on the five outcome measures quantitatively examined in this study, which include knowledge of child development, parenting confidence and support, depression, self-esteem, and life skills. Initial differences existed between Hispanic and non-Hispanic participants in knowledge of child development and life skills, with non-Hispanic participants reporting higher knowledge of child development and greater life skills. Non-Hispanic participants, however, did not make greater gains than their Hispanic participants after being in the program. Qualitative results indicate that skills gained by Hispanic participants helped them acculturate in the American society, whereas for non-Hispanic participants the program helped achieve a sense of purpose and direction in life and create a better life for themselves and their family. Close

• 24. [Article] Bringing the River Back: Working with Landowners on Willamette River Restoration

  The Willamette River has gone through extensive changes since Euro American settlement – changes that have reduced channel connectivity, destroyed important habitat for species and vastly undermined floodwater ...

  Citation × Citation Citation Abstract Copy Title: Bringing the River Back: Working with Landowners on Willamette River Restoration Author: Institute for Natural Resources, Greenbelt Land Trust, McCune, Myrica, Lurie, Sue, River Design, Duncan, Sally The Willamette River has gone through extensive changes since Euro American settlement – changes that have reduced channel connectivity, destroyed important habitat for species and vastly undermined floodwater storage capacity. Efforts to preserve portions of the river have a controversial legacy that has left lingering suspicions of government involvement in any activity that includes private lands. Nonetheless, there are opportunities for willing landowners to work with governmental and non-governmental partners to design and implement voluntary restoration projects which can provide financial and land use benefits. The river’s floodplain can be an asset and a resource beyond its usefulness for agricultural production. This report is part technical guide, part story based on interviews we conducted with different interests. We have separated out the landowners’ viewpoints and experience to make clear the importance of understanding that critical central element in restoration planning. The Harkens Lake area of the Willamette River near Monroe, Oregon, is a priority conservation area detailed in the 2002 Willamette River Basin Planning Atlas: Trajectories of Environmental and Ecological Change. The Horning families who own property in the Harkens Lake area have teamed with several partners to design and implement a restoration project as a way to, in their words, bring what was once a living area back to life as a way to give back to the river. If the potential for restoration is to be realized, landowners and their partners need to be aware of the multiple associated challenges and ways to work through them. Restoration is still new to many landowners, and projects can become complicated fairly quickly. The concept of lead project partners as case managers for landowners is critical. This approach will help landowners define their needs and expectations, develop the level of trust essential to project success, and ensure that landowners are not overwhelmed with the complexity of financing, the demands of design and permitting, and the challenge of incorporating good science. Landowners also need to know that there is a broad range of restoration programs and tools available, along with associated funding. The sweep of these programs and tools can be confusing. Though the Harken’s Lake project has not yet required permits from regulatory agencies, many stakeholders interviewed for this report identified permitting as one of the most perennially vexing parts of project implementation. It typically requires cooperation among different agencies at different levels of government, and can take from three months to three years, requiring a great deal of patience on the part of landowners and matching perseverance on the part of project partners. Finally, as the Harkens Lake story illustrates, a vital concept that may help ensure successful processes is making certain project partners and landowners discuss critical timing issues, align process steps accordingly, and develop two-way assurances that serve as accountability measures and benchmarks for progress. Those involved with the Harkens Lake restoration project expressed clear hopes: that the project will be a model for more restoration on the mainstem of the Willamette, that restoration will provide good compensation to property owners so that restoration represents a practical addition to agricultural business portfolios, and that landowners will feel good about their legacy in its benefits to the health of the river. The report should be of interest to landowners, agencies and others in the conservation community, and academics. We emphasize that it is a case study of one landowner’s experience, and the pool of associated interview participants was limited. Typical of single case studies, the experiences and outcomes cannot be generalized. There are nonetheless many elements of the study that represent long-standing landowner issues and concerns still shared by many, as indicated by the landowners and by several of the people we interviewed. Title: Bringing the River Back: Working with Landowners on Willamette River Restoration Author: Institute for Natural Resources, Greenbelt Land Trust, McCune, Myrica, Lurie, Sue, River Design, Duncan, Sally The Willamette River has gone through extensive changes since Euro American settlement – changes that have reduced channel connectivity, destroyed important habitat for species and vastly undermined floodwater storage capacity. Efforts to preserve portions of the river have a controversial legacy that has left lingering suspicions of government involvement in any activity that includes private lands. Nonetheless, there are opportunities for willing landowners to work with governmental and non-governmental partners to design and implement voluntary restoration projects which can provide financial and land use benefits. The river’s floodplain can be an asset and a resource beyond its usefulness for agricultural production. This report is part technical guide, part story based on interviews we conducted with different interests. We have separated out the landowners’ viewpoints and experience to make clear the importance of understanding that critical central element in restoration planning. The Harkens Lake area of the Willamette River near Monroe, Oregon, is a priority conservation area detailed in the 2002 Willamette River Basin Planning Atlas: Trajectories of Environmental and Ecological Change. The Horning families who own property in the Harkens Lake area have teamed with several partners to design and implement a restoration project as a way to, in their words, bring what was once a living area back to life as a way to give back to the river. If the potential for restoration is to be realized, landowners and their partners need to be aware of the multiple associated challenges and ways to work through them. Restoration is still new to many landowners, and projects can become complicated fairly quickly. The concept of lead project partners as case managers for landowners is critical. This approach will help landowners define their needs and expectations, develop the level of trust essential to project success, and ensure that landowners are not overwhelmed with the complexity of financing, the demands of design and permitting, and the challenge of incorporating good science. Landowners also need to know that there is a broad range of restoration programs and tools available, along with associated funding. The sweep of these programs and tools can be confusing. Though the Harken’s Lake project has not yet required permits from regulatory agencies, many stakeholders interviewed for this report identified permitting as one of the most perennially vexing parts of project implementation. It typically requires cooperation among different agencies at different levels of government, and can take from three months to three years, requiring a great deal of patience on the part of landowners and matching perseverance on the part of project partners. Finally, as the Harkens Lake story illustrates, a vital concept that may help ensure successful processes is making certain project partners and landowners discuss critical timing issues, align process steps accordingly, and develop two-way assurances that serve as accountability measures and benchmarks for progress. Those involved with the Harkens Lake restoration project expressed clear hopes: that the project will be a model for more restoration on the mainstem of the Willamette, that restoration will provide good compensation to property owners so that restoration represents a practical addition to agricultural business portfolios, and that landowners will feel good about their legacy in its benefits to the health of the river. The report should be of interest to landowners, agencies and others in the conservation community, and academics. We emphasize that it is a case study of one landowner’s experience, and the pool of associated interview participants was limited. Typical of single case studies, the experiences and outcomes cannot be generalized. There are nonetheless many elements of the study that represent long-standing landowner issues and concerns still shared by many, as indicated by the landowners and by several of the people we interviewed. Close

• 25. [Article] An evaluation of a water, sanitation, and hygiene (WASH) program for rural communities in northern Afghanistan

  The Water, Sanitation and Hygiene (WASH) sector of international development works to increase access to sustainable, safe water and improved sanitation. Currently, at least 780 million people live without ...

  Citation × Citation Citation Abstract Copy Title: An evaluation of a water, sanitation, and hygiene (WASH) program for rural communities in northern Afghanistan Author: Costello, Denise H. The Water, Sanitation and Hygiene (WASH) sector of international development works to increase access to sustainable, safe water and improved sanitation. Currently, at least 780 million people live without clean drinking water and 2.5 billion without access to improved sanitation (UNICEF & World Health Organization, 2012). Lack of access to these human rights is a major cause of diarrheal disease, which annually kills nearly 760,000 children under the age of five. Many institutions, including the United Nations (UN), non-governmental organizations (NGOs), and local governments are working to resolve this inequality by increasing safe water access, providing sanitation facilities, and improving knowledge and practice of healthy hygiene behaviors. Implementing agencies often self-monitor their efforts and, due to funding challenges, only through the life of the project. This study attempts to evaluate the longer-term effectiveness of an NGO's WASH program in Balkh Province, Afghanistan by investigating five questions, post program 1) was access to safe drinking water improved; 2) how is the spatial distribution of households relative to water sources related to safety of stored drinking water; 3) was there an increase in WASH knowledge; 4) was there an increase in WASH practices; 5) was stored household drinking water safe for consumption? In August to September 2012, an evaluation was conducted of the longer-term effectiveness of a 2009 WASH program in northern Afghanistan. A total of 59 households from four villages took part in the follow-up survey that collected information regarding drinking water, sanitation, health behaviors, and storage or treatment of drinking water. With permission of the participants, drinking water samples were collected and tested for any presence of E. coli, an indicator of fecal contamination. Additionally, samples were taken and analyzed from 15 drinking water sources, 13 of which were public boreholes. Lastly, a Garmin GPS device was used to collect latitude and longitude location of important points during the field research. This information was used to conduct a spatial analysis of well distribution throughout the villages. Survey results showed increases in several beneficial health behaviors, such as using boreholes as the main source of household drinking water, having a specific place to wash hands after using toilet facilities, and having soap in that specific area. Also, based on results of the spatial analysis, access to improved water sources was increased. The practice of treating water in the home dropped significantly. Biosand Filter technology introduced during the WASH program had been adopted by only a small percentage of households. Of the 54 surveyed households that gave permission to sample, 40 had drinking water that tested positive for presence of E. coli. In contrast, a majority of borehole samples provided water that was free of E. coli. Lastly, by examining the spatial distribution of households, it was found that all households beyond 300m from a borehole had drinking water with a presence of E coli. These outcomes make two suggestions. One is that using "1000m from an improved source" as an indicator of accessibility may be too great a distance for households that must collect and carry water, especially when a closer, though contaminated, water option exists. The second is a need for longer term follow-up, especially as behavior change is one of the main goals of the program. More investigation into why families have not adopted handwashing and in home water treatment to a greater extent would be beneficial in creating a stronger WASH program that has greater health impacts. Extended programming is challenging when NGOs are reliant on external funding for program costs. Advocating to funders the importance of longer term monitoring and evaluation as well as reoccurring education programs, could be a vital next step. Title: An evaluation of a water, sanitation, and hygiene (WASH) program for rural communities in northern Afghanistan Author: Costello, Denise H. The Water, Sanitation and Hygiene (WASH) sector of international development works to increase access to sustainable, safe water and improved sanitation. Currently, at least 780 million people live without clean drinking water and 2.5 billion without access to improved sanitation (UNICEF & World Health Organization, 2012). Lack of access to these human rights is a major cause of diarrheal disease, which annually kills nearly 760,000 children under the age of five. Many institutions, including the United Nations (UN), non-governmental organizations (NGOs), and local governments are working to resolve this inequality by increasing safe water access, providing sanitation facilities, and improving knowledge and practice of healthy hygiene behaviors. Implementing agencies often self-monitor their efforts and, due to funding challenges, only through the life of the project. This study attempts to evaluate the longer-term effectiveness of an NGO's WASH program in Balkh Province, Afghanistan by investigating five questions, post program 1) was access to safe drinking water improved; 2) how is the spatial distribution of households relative to water sources related to safety of stored drinking water; 3) was there an increase in WASH knowledge; 4) was there an increase in WASH practices; 5) was stored household drinking water safe for consumption? In August to September 2012, an evaluation was conducted of the longer-term effectiveness of a 2009 WASH program in northern Afghanistan. A total of 59 households from four villages took part in the follow-up survey that collected information regarding drinking water, sanitation, health behaviors, and storage or treatment of drinking water. With permission of the participants, drinking water samples were collected and tested for any presence of E. coli, an indicator of fecal contamination. Additionally, samples were taken and analyzed from 15 drinking water sources, 13 of which were public boreholes. Lastly, a Garmin GPS device was used to collect latitude and longitude location of important points during the field research. This information was used to conduct a spatial analysis of well distribution throughout the villages. Survey results showed increases in several beneficial health behaviors, such as using boreholes as the main source of household drinking water, having a specific place to wash hands after using toilet facilities, and having soap in that specific area. Also, based on results of the spatial analysis, access to improved water sources was increased. The practice of treating water in the home dropped significantly. Biosand Filter technology introduced during the WASH program had been adopted by only a small percentage of households. Of the 54 surveyed households that gave permission to sample, 40 had drinking water that tested positive for presence of E. coli. In contrast, a majority of borehole samples provided water that was free of E. coli. Lastly, by examining the spatial distribution of households, it was found that all households beyond 300m from a borehole had drinking water with a presence of E coli. These outcomes make two suggestions. One is that using "1000m from an improved source" as an indicator of accessibility may be too great a distance for households that must collect and carry water, especially when a closer, though contaminated, water option exists. The second is a need for longer term follow-up, especially as behavior change is one of the main goals of the program. More investigation into why families have not adopted handwashing and in home water treatment to a greater extent would be beneficial in creating a stronger WASH program that has greater health impacts. Extended programming is challenging when NGOs are reliant on external funding for program costs. Advocating to funders the importance of longer term monitoring and evaluation as well as reoccurring education programs, could be a vital next step. Close

• 26. [Article] Occupational Safety and Health in Alaska's Seafood Processing Industry

  Although the seafood processing industry is vital to Alaska’s economy, limited research has addressed workers’ safety and health. Federal and state regulators have classified both offshore and onshore ...

  Citation × Citation Citation Abstract Copy Title: Occupational Safety and Health in Alaska's Seafood Processing Industry Author: Syron, Laura N. Although the seafood processing industry is vital to Alaska’s economy, limited research has addressed workers’ safety and health. Federal and state regulators have classified both offshore and onshore seafood processing worksites in Alaska as high-hazard environments; however, there is a dearth of published information on safety and health outcomes in the industry. There is evidence from the Survey of Occupational Injuries and Illnesses that these workers are at high risk for nonfatal injuries and illnesses. Nonfatal incidents can be severe, resulting in workers' lowered productivity, lost worktime and wages, lowered quality of life, and disability. Research is needed to inform targeted injury and illness prevention strategies in this economically important and understudied industry. To conduct surveillance research on safety and health in this industry, we utilized two data sources – one which captured information on offshore worksites, and another which captured information on onshore worksites. To research safety and health programs at Alaskan worksites, we engaged stakeholders who directed and managed these programs. US Coast Guard reports were utilized to determine patterns of traumatic injury characteristics and circumstances, as well as identify modifiable worksite hazards, among offshore seafood processors working in Alaskan waters during 2010-2015. One fatal and 304 nonfatal injuries were reported to the Coast Guard across multiple fleets of catcher-processor and mothership vessels. The most frequently occurring injuries were: by nature of injury, sprains/strains/tears (75, 25%), contusions (50, 16%), and fractures (45, 15%); by body part affected, upper extremities (121, 40%) and trunk (75, 25%); by event/exposure resulting in injury, contact with objects and equipment (150, 49%), and overexertion and bodily reaction (76, 25%); and by source of injury, processing equipment and machinery (150, 49%). The work processes most frequently associated with injuries were: processing seafood on the production line (68, 22%); stacking blocks/bags of frozen product (50, 17%); and repairing/maintaining/cleaning factory equipment (28, 9%). Some injuries, such as serious back injuries, intracranial injuries, and finger crushing or amputations, had the potential to lead to long-term disability. Alaska workers' compensation claims data were utilized to (a) estimate the risk of nonfatal injuries and illnesses, (b) determine patterns of incident characteristics and circumstances, and (c) identify modifiable workplace hazards among onshore workers in the seafood processing industry during 2014-2015. During the study period, 2,194 claims were accepted for nonfatal injuries and illnesses. The average annual claim rate was 48 per 1,000 workers. The most frequently occurring injuries and illnesses, were: by nature, sprains/strains/tears (747, 36%), contusions (353, 17%), and lacerations/punctures (227, 11%); by body part, upper extremities (880, 43%) and trunk (422, 21%); and by event/exposure, contact with objects and equipment (721, 36%) and overexertion and bodily reaction (697, 35%). Incidents resulting from line production activities (n=623) frequently involved: repetitive motion; overexertion while handling trays/pans, basket/buckets, and fish/shellfish; and coming into contact with fish/shellfish, trays/pans, and processing machinery. Incidents resulting from material handling activities (n=339) frequently involved overexertion while handling boxes/cartons/bags, and falls/slips/trips. Interviews with safety and health directors/managers were conducted to investigate: (a) offshore and onshore worksite and workforce characteristics; (b) safety and health program features; (c) economic factors influencing programs; and (d) program challenges and successes. Based on the common findings across these topics, we identified workplace factors that could be modified to improve safety and health. Interview participants reported directing/managing programs for 68% of the 25,000 workers in this Alaskan industry. The 14 participants represented 13 companies that operated 32 onshore plants and 30 vessels, employing an estimated 17,000 workers at peak season, of which 84% were processors. Participants noted widely varying degrees of program buy-in and engagement from management and workers, ranging from basic compliance with standards to full partnerships for carrying out best practices. While some participants reported that fostering a proactive safety culture and “prevention mindset” were among their greatest successes, others discussed the challenges of overcoming an “old guard mentality” that did not prioritize safety. Most participants noted that language barriers among the diverse workforce presented difficulties when communicating, especially during training. Ergonomic hazards and long work hours were frequently reported as areas of concern. The epidemiologic studies identified similar patterns of injuries and modifiable hazards in offshore and onshore worksites. Among both seafood processors in vessels, and workers of various occupations in plants, preventing musculoskeletal injuries – particularly to the upper extremities and trunk – is paramount for improving occupational health. In offshore work environments, hazard control measures should target: (a) overexertion from lifting and lowering objects and equipment; (b) equipment and boxes falling and striking workers; (c) workers being caught in running machinery during regular operations; and (d) slips, trips, and falls. Similarly, in onshore plants, hazard control measures should target: (a) repetitive motion, overexertion, and contact with equipment during line production; (b) overexertion due to manually lifting, lowering, pushing, and pulling materials and equipment; and (c) slips, trips, and falls. Interviewing safety and health directors and managers uncovered additional workplace factors that could be modified in order to improve workers’ safety and health. These factors included: worksite manager training; worker training; adoption of ergonomics; work hours; knowledge sharing within the industry; and organizational aspects related to safety culture. Participants reported that fully engaging workers in all aspects of their safety and health programs was beneficial to their programs’ success. To assist industry members with protecting workers’ safety and health, occupational health practitioners and researchers could support the development and evaluation of training for limited-English-speaking-workers, fatigue risk management systems, and ergonomic solutions. In the long-term, this research project will help prevent injuries and illnesses among workers in the seafood processing industry. Title: Occupational Safety and Health in Alaska's Seafood Processing Industry Author: Syron, Laura N. Although the seafood processing industry is vital to Alaska’s economy, limited research has addressed workers’ safety and health. Federal and state regulators have classified both offshore and onshore seafood processing worksites in Alaska as high-hazard environments; however, there is a dearth of published information on safety and health outcomes in the industry. There is evidence from the Survey of Occupational Injuries and Illnesses that these workers are at high risk for nonfatal injuries and illnesses. Nonfatal incidents can be severe, resulting in workers' lowered productivity, lost worktime and wages, lowered quality of life, and disability. Research is needed to inform targeted injury and illness prevention strategies in this economically important and understudied industry. To conduct surveillance research on safety and health in this industry, we utilized two data sources – one which captured information on offshore worksites, and another which captured information on onshore worksites. To research safety and health programs at Alaskan worksites, we engaged stakeholders who directed and managed these programs. US Coast Guard reports were utilized to determine patterns of traumatic injury characteristics and circumstances, as well as identify modifiable worksite hazards, among offshore seafood processors working in Alaskan waters during 2010-2015. One fatal and 304 nonfatal injuries were reported to the Coast Guard across multiple fleets of catcher-processor and mothership vessels. The most frequently occurring injuries were: by nature of injury, sprains/strains/tears (75, 25%), contusions (50, 16%), and fractures (45, 15%); by body part affected, upper extremities (121, 40%) and trunk (75, 25%); by event/exposure resulting in injury, contact with objects and equipment (150, 49%), and overexertion and bodily reaction (76, 25%); and by source of injury, processing equipment and machinery (150, 49%). The work processes most frequently associated with injuries were: processing seafood on the production line (68, 22%); stacking blocks/bags of frozen product (50, 17%); and repairing/maintaining/cleaning factory equipment (28, 9%). Some injuries, such as serious back injuries, intracranial injuries, and finger crushing or amputations, had the potential to lead to long-term disability. Alaska workers' compensation claims data were utilized to (a) estimate the risk of nonfatal injuries and illnesses, (b) determine patterns of incident characteristics and circumstances, and (c) identify modifiable workplace hazards among onshore workers in the seafood processing industry during 2014-2015. During the study period, 2,194 claims were accepted for nonfatal injuries and illnesses. The average annual claim rate was 48 per 1,000 workers. The most frequently occurring injuries and illnesses, were: by nature, sprains/strains/tears (747, 36%), contusions (353, 17%), and lacerations/punctures (227, 11%); by body part, upper extremities (880, 43%) and trunk (422, 21%); and by event/exposure, contact with objects and equipment (721, 36%) and overexertion and bodily reaction (697, 35%). Incidents resulting from line production activities (n=623) frequently involved: repetitive motion; overexertion while handling trays/pans, basket/buckets, and fish/shellfish; and coming into contact with fish/shellfish, trays/pans, and processing machinery. Incidents resulting from material handling activities (n=339) frequently involved overexertion while handling boxes/cartons/bags, and falls/slips/trips. Interviews with safety and health directors/managers were conducted to investigate: (a) offshore and onshore worksite and workforce characteristics; (b) safety and health program features; (c) economic factors influencing programs; and (d) program challenges and successes. Based on the common findings across these topics, we identified workplace factors that could be modified to improve safety and health. Interview participants reported directing/managing programs for 68% of the 25,000 workers in this Alaskan industry. The 14 participants represented 13 companies that operated 32 onshore plants and 30 vessels, employing an estimated 17,000 workers at peak season, of which 84% were processors. Participants noted widely varying degrees of program buy-in and engagement from management and workers, ranging from basic compliance with standards to full partnerships for carrying out best practices. While some participants reported that fostering a proactive safety culture and “prevention mindset” were among their greatest successes, others discussed the challenges of overcoming an “old guard mentality” that did not prioritize safety. Most participants noted that language barriers among the diverse workforce presented difficulties when communicating, especially during training. Ergonomic hazards and long work hours were frequently reported as areas of concern. The epidemiologic studies identified similar patterns of injuries and modifiable hazards in offshore and onshore worksites. Among both seafood processors in vessels, and workers of various occupations in plants, preventing musculoskeletal injuries – particularly to the upper extremities and trunk – is paramount for improving occupational health. In offshore work environments, hazard control measures should target: (a) overexertion from lifting and lowering objects and equipment; (b) equipment and boxes falling and striking workers; (c) workers being caught in running machinery during regular operations; and (d) slips, trips, and falls. Similarly, in onshore plants, hazard control measures should target: (a) repetitive motion, overexertion, and contact with equipment during line production; (b) overexertion due to manually lifting, lowering, pushing, and pulling materials and equipment; and (c) slips, trips, and falls. Interviewing safety and health directors and managers uncovered additional workplace factors that could be modified in order to improve workers’ safety and health. These factors included: worksite manager training; worker training; adoption of ergonomics; work hours; knowledge sharing within the industry; and organizational aspects related to safety culture. Participants reported that fully engaging workers in all aspects of their safety and health programs was beneficial to their programs’ success. To assist industry members with protecting workers’ safety and health, occupational health practitioners and researchers could support the development and evaluation of training for limited-English-speaking-workers, fatigue risk management systems, and ergonomic solutions. In the long-term, this research project will help prevent injuries and illnesses among workers in the seafood processing industry. Close

• 27. [Image] A strategy for achieving healthy watersheds in Oregon

  	"January 2001."
  	Citation × Citation Citation Abstract Copy Title: A strategy for achieving healthy watersheds in Oregon Author: Oregon Watershed Enhancement Board Year: 2001, 2004 "January 2001." Title: A strategy for achieving healthy watersheds in Oregon Author: Oregon Watershed Enhancement Board Year: 2001, 2004 "January 2001." Close

• 28. [Image] A framework for ecosystem management in the interior Columbia Basin and portions of the Klamath and Great Basins

  	Haynes, Richard W.; Graham, Russell T.; Quigley, Thomas M., tech. eds. 1996. A framework for ecosystem management in the Interior Columbia Basin including portions of the Klamath and Great Basins. Gen. ...
  	Citation × Citation Citation Abstract Copy Title: A framework for ecosystem management in the interior Columbia Basin and portions of the Klamath and Great Basins Year: 1996, 2005 Haynes, Richard W.; Graham, Russell T.; Quigley, Thomas M., tech. eds. 1996. A framework for ecosystem management in the Interior Columbia Basin including portions of the Klamath and Great Basins. Gen. Tech. Rep. PNW-GTR-374. Portland, OR; U.S. Department of Agriculture, Forest Service, Pacific Northwest Research Station. 66 p. A framework for ecosystem management is proposed. This framework assumes the purpose of ecosystem management is to maintain the integrity of ecosystems over time and space. It is based on four ecosystem principles: ecosystems are dynamic, can be viewed as hierarchies with temporal and spatial dimensions, have limits, and are relatively unpredictable. This approach recognizes that people are part of ecosystems and that stewardship must be able to resolve tough challenges including how to meet multiple demands with finite resources. The framework describes a general planning model for ecosystem management that has four iterative steps: monitoring, assessment, decision-making, and implementation. Since ecosystems cross jurisdictional lines, the implementation of the framework depends on partnerships among land managers, the scientific community, and stakeholders. It proposes that decision-making be based on information provided by the best available science and the most appropriate technologies for land management. Keywords: Ecosystem assessment, ecosystem principles, ecosystem management, planning models, management goals, risk analysis. Title: A framework for ecosystem management in the interior Columbia Basin and portions of the Klamath and Great Basins Year: 1996, 2005 Haynes, Richard W.; Graham, Russell T.; Quigley, Thomas M., tech. eds. 1996. A framework for ecosystem management in the Interior Columbia Basin including portions of the Klamath and Great Basins. Gen. Tech. Rep. PNW-GTR-374. Portland, OR; U.S. Department of Agriculture, Forest Service, Pacific Northwest Research Station. 66 p. A framework for ecosystem management is proposed. This framework assumes the purpose of ecosystem management is to maintain the integrity of ecosystems over time and space. It is based on four ecosystem principles: ecosystems are dynamic, can be viewed as hierarchies with temporal and spatial dimensions, have limits, and are relatively unpredictable. This approach recognizes that people are part of ecosystems and that stewardship must be able to resolve tough challenges including how to meet multiple demands with finite resources. The framework describes a general planning model for ecosystem management that has four iterative steps: monitoring, assessment, decision-making, and implementation. Since ecosystems cross jurisdictional lines, the implementation of the framework depends on partnerships among land managers, the scientific community, and stakeholders. It proposes that decision-making be based on information provided by the best available science and the most appropriate technologies for land management. Keywords: Ecosystem assessment, ecosystem principles, ecosystem management, planning models, management goals, risk analysis. Close

• 29. [Image] The Water Report - Hydro relicensing OR/CA: fish passage transport

  	Only portions of issues of The Water Report are available in the Klamath Waters Digital Library. See the full report at http://www.thewaterreport.com/
  	Citation × Citation Citation Abstract Copy Title: The Water Report - Hydro relicensing OR/CA: fish passage transport Author: Envirotech Publications Year: 2006, 2008 Only portions of issues of The Water Report are available in the Klamath Waters Digital Library. See the full report at http://www.thewaterreport.com/ Title: The Water Report - Hydro relicensing OR/CA: fish passage transport Author: Envirotech Publications Year: 2006, 2008 Only portions of issues of The Water Report are available in the Klamath Waters Digital Library. See the full report at http://www.thewaterreport.com/ Close

• 30. [Image] The Water Report - Tribal water rights update

  	Only portions of issues of The Water Report are available in the Klamath Waters Digital Library. See the full report at http://www.thewaterreport.com/.
  	Citation × Citation Citation Abstract Copy Title: The Water Report - Tribal water rights update Author: Envirotech Publications Year: 2006, 2008 Only portions of issues of The Water Report are available in the Klamath Waters Digital Library. See the full report at http://www.thewaterreport.com/. Title: The Water Report - Tribal water rights update Author: Envirotech Publications Year: 2006, 2008 Only portions of issues of The Water Report are available in the Klamath Waters Digital Library. See the full report at http://www.thewaterreport.com/. Close