Melissa L. Finucane

Evidence for the Convergence Model: The Emergence of Highly Pathogenic Avian Influenza (H5N1) in Viet Nam.

Building on a series of ground breaking reviews that first defined and drew attention to emerging infectious diseases (EID), the ‘convergence model’ was proposed to explain the multifactorial causality of disease emergence. The model broadly hypothesizes disease emergence is driven by the co-incidence of genetic, physical environmental, ecological, and social factors. We developed and tested a model of the emergence of highly pathogenic avian influenza (HPAI) H5N1 based on suspected convergence factors that are mainly associated with land-use change. Building on previous geospatial statistical studies that identified natural and human risk factors associated with urbanization, we added new factors to test whether causal mechanisms and pathogenic landscapes could be more specifically identified. Our findings suggest that urbanization spatially combines risk factors to produce particular types of peri-urban landscapes with significantly higher HPAI H5N1 emergence risk. The work highlights that peri-urban areas of Viet Nam have higher levels of chicken densities, duck and geese flock size diversities, and fraction of land under rice or aquaculture than rural and urban areas. We also found that land-use diversity, a surrogate measure for potential mixing of host populations and other factors that likely influence viral transmission, significantly improves the model’s predictability. Similarly, landscapes where intensive and extensive forms of poultry production overlap were found at greater risk. These results support the convergence hypothesis in general and demonstrate the potential to improve EID prevention and control by combing geospatial monitoring of these factors along with pathogen surveillance programs.

An Exploration of How Perceptions of the Risk of Avian Influenza in Poultry Relate to Urbanization in Vietnam

This research examined how perceptions of outbreaks of highly pathogenic avian influenza (HPAI) subtype H5N1 in poultry are related to urbanization. Via in-depth interviews with village leaders, household farmers, and large farm operators in modern, transitional, and traditional communes in the north of Vietnam, we explored behaviors, attitudes, cultural values, and traditions that might amplify or attenuate HPAI outbreaks. We also explored conceptualizations of urbanization and its impacts on animal husbandry and disease outbreaks. Qualitative theme analyses identified the key impacts, factors related to HPAI outbreaks, and disease prevention and management strategies. The analyses also highlighted how urbanization improves some aspects of life (e.g., food security, family wealth and health, more employment opportunities, and improved infrastructure), but simultaneously poses significant challenges for poultry farming and disease management. Awareness of qualitative aspects of HPAI risk perceptions and behaviors and how they vary with urbanization processes may help to improve the prevention and management of emerging infectious diseases.

Understanding the Climate-Sensitive Decisions and Information Needs of Freshwater Resource Managers in Hawaii

AbstractUnderstanding how climate science can be useful in decisions about the management of freshwater resources requires knowledge of decision makers, their climate-sensitive decisions, and the context in which the decisions are being made. A mixed-methods study found that people managing freshwater resources in Hawaii are highly educated and experienced in diverse professions, they perceive climate change as posing a worrisome risk, and they would like to be better informed about how to adapt to climate change. Decision makers with higher climate literacy seem to be more comfortable dealing with uncertain information. Those with lower climate literacy seem to be more trusting of climate information from familiar sources. Freshwater managers in Hawaii make a wide range of climate-sensitive decisions. These decisions can be characterized on several key dimensions including purpose (optimization and evaluation), time horizon (short term and long term), level of information uncertainty (known, uncertain, d...

CAHPS and Comments: How Closed-Ended Survey Questions and Narrative Accounts Interact in the Assessment of Patient Experience

Objectives: To investigate whether content from patient narratives explains variation in patients’ primary care provider (PCP) ratings beyond information from the closed-ended questions of the Consumer Assessment of Healthcare Providers and Systems (CAHPS) Clinician and Group Survey and whether the relative placement of closed- and open-ended survey questions affects either the content of narratives or the CAHPS composite scores. Methods: Members of a standing Internet panel (N = 332) were randomly assigned to complete a CAHPS survey that was either preceded or followed by a set of open-ended questions about how well their PCP meets their expectations and how they relate to their PCP. Results: Narrative content from healthier patients explained only an additional 2% beyond the variation in provider ratings explained by CAHPS composite measures. Among sicker patients, narrative content explained an additional 10% of the variation. The relative placement of closed- and open-ended questions had little impact on narratives or CAHPS scores. Conclusion: Incorporating a protocol for eliciting narratives into a patient experience survey results in minimal distortion of patient feedback. Narratives from sicker patients help explain variation in provider ratings.

A Conceptual Framework for Analyzing Social-Ecological Models of Emerging Infectious Diseases

Unraveling mechanisms underlying new and reemerging infectious diseases (EID) requires exploring complex interactions within and among coupled natural and human (CNH) systems. To address this difficult scientific problem, we need to understand how transformations in social-ecological systems caused by multifaceted interactions with anthropogenic environmental changes such as urbanization, agricultural transformations, and natural habitat alterations, produce feedbacks that affect natural communities and ultimately their pathogens, animal host, and human populations. Focusing on the complex interactions among natural and human systems at diverse spatial, temporal, and organizational scales, we describe the development of a framework for analyzing social-ecological models, to understand how these systems function and the processes through which these systems interact with each other to influence disease outbreaks. To address multi-scale issues within the framework, we draw upon multiple social science theories and methods (e.g., environmental economics, geography, decision and risk science, urban and regional development, and spatial information science). We posit that the framework helps to identify potential vulnerabilities of CNH systems to disturbances, describing important elements as a starting point for the development and testing of more general CNH systems. We also posit that transformations in the elements and how they relate to each other are key in determining the robustness of CNH systems. Given the importance and difficulty of research on social-ecological systems, we recommend a carefully considered theoretical rationale and a model-guided methodological approach. We conclude that no single theory or method is sufficient to explain complex phenomena such as EID and the relationships between factors influencing disease outbreaks. Integrated approaches are arguably the best way to provide an in-depth description and analysis of a complex problem.

Understanding the climate-sensitive decisions and information needs of island communities

Climate variability and change present significant challenges for island communities in the Pacific and Indian Ocean regions. Understanding how climate science can be useful for island communities requires knowledge of decision-makers, their climate-sensitive decisions, and the context in which the decisions are being made. In this paper we report on an interdisciplinary research and outreach effort called the Pacific Islands Regional Climate Assessment. We describe potential impacts from the changing climate for island communities, including food and water security, disaster preparedness, human migration and national security. We highlight transferable lessons learned related to building resiliency, engaging innovative leadership and supporting integrated research and outreach.

A Rigorous Approach to Large-Scale Elicitation and Analysis of Patient Narratives

Patient narratives have emerged as promising vehicles for making health care more responsive by helping clinicians to better understand their patients’ expectations, perceptions, or concerns and encouraging consumers to engage with information about quality. A growing number of websites incorporate patients’ comments. But existing comments have fragmentary content, fail to represent less vocal patients, and can be manipulated to “manage” providers’ reputations. In this article, we offer the first empirical test of the proposition that patient narratives can be elicited rigorously and reliably using a five-question protocol that can be incorporated into large-scale patient experience surveys. We tested whether elicited narratives about outpatient care are complete (report all facets of patient experience), balanced (convey an accurate mix of positive and negative events), meaningful (have a coherent storyline), and representative (draw fulsome narratives from all relevant subsets of patients). The tested protocol is strong on balance and representativeness, more mixed on completeness and meaningfulness.

The SelectMD 2.0 Provider Choice Experiment: Methodological Overview

This document has not been formally edited. RANDs publications do not necessarily reflect the opinions of its research clients and sponsors. is a registered trademark. ii Preface This document provides a detailed methodological overview of the SelectMD 2.0 provider choice experiment. This study uses an experimental design to test different methods of incorporating patient comments along with Consumer Assessment of Healthcare Providers and Services (CAHPS) survey results, Healthcare Effectiveness Data and Information Set (HEDIS)-like measures of effective clinical treatments, and indicators of patient safety in web-based physician quality reports. In addition, the study allowed for exploration of the role of patient navigators in affecting provider choice. The study aims to help the Agency for Healthcare Research and Quality (AHRQ) better understand how people choose a doctor as their regular source of medical care and advice. The SelectMD 2.0 provider choice experiment and the preparation of this report were supported by two cooperative agreements from AHRQ (2U18HS016980 and 1U18HS016978) to RAND and Yale University, respectively. This study was reviewed and approved by the RAND Human Subjects Protection Committee, RANDs Institutional Review Board (IRB) to review research involving human subjects. Acknowledgments We would like to thank the following people who helped the SelectMD 2.0 experiment come to fruition: for providing on-site supervision of the patient navigators x Caren Ginsberg and Chris Crofton, our project officers at ARHQ, for their support of this study x Lacey Rose Barre for her work developing the coding scheme for open-ended responses on the survey questions and other research assistance x Lane Hanson and Chaz Felix for their work coding open-ended survey responses x Bennie Osafo-Darko at Westat for her support of our teams research. The SelectMD 2.0 study used an experimental design to test different methods of incorporating patient comments about providers along with CAHPS survey results, HEDIS-like measures of effective clinical treatments, and indicators of patient safety in web-based physician quality reports. In addition, the study allowed for exploration of the role of patient navigators in affecting provider choice. The SelectMD 2.0 experiment was designed to achieve the following goals, each elaborated in more detail below: 1. Provide further insight into how to incorporate patient comments into health care quality reporting sites. 2. Test the effects of the provision of roll-up measures on decisionmaking. 3. Test the effects of patient navigators on decisionmaking. Provide further insight into how to incorporate patient comments into health care …

Choosing Doctors Wisely: Can Assisted Choice Enhance Patients’ Selection of Clinicians?:

We conducted a simulated clinician-choice experiment, comparing choices and decision-making processes of participants (N = 688) randomized among four experimental arms: a conventional website reporting only quantitative performance information, a website reporting both qualitative (patient comments) and quantitative information, the second website augmented by a decision aid (labeling of patient comments), and the decision-aided website further augmented by the presence of a trained navigator. Introducing patient comments enhanced engagement with the quality information but led to a decline in decision quality, particularly the consistency of choices with consumers’ stated preferences. Labeling comments helped erase the decline in decision quality, although the highest percentage of preference-congruent choices was seen in the navigator arm. Engagement with the quality information and satisfaction with choices available were likewise highest in the navigator arm. Findings held for high- and low-skilled decision makers. Thus, navigator assistance may be a promising strategy for equitably promoting higher quality choices in information-rich contexts.

Perceived Risk of Avian Influenza and Urbanization in Northern Vietnam

Highly pathogenic avian influenza (HPAI) is an important public health concern because of potential for widespread morbidity and mortality in humans and poultry and associated devastating economic losses. We examined how perceptions of the risk of HPAI in poultry vary across communes/wards in the north of Vietnam at different levels of urbanization (rural, peri-urban, urban). Analyses of questionnaire responses from 1081 poultry raisers suggested that the perceived risk of HPAI in poultry was highest in peri-urban and rural settings. We also found that perceived risk was higher when respondents rated settings in which they did not live and that the process of change is related to perceived risk. Compared with others, respondents in peri-urban areas reported less disease management planning; respondents in rural areas reported less ability to separate infected poultry. These findings are consistent with, and add to, the limited previous research on the perceived risk of HPAI in poultry in developing countries. What is new in the present findings is that we describe how urbanization is related to people’s perceptions of and ability to respond appropriately to variations in their environment. In particular, the inability to respond is not necessarily because of an inability to perceive change. Rather, rapid and extensive change poses different challenges for poultry management as communes move from rural to peri-urban to urban settings. Our results suggest that health promotion campaigns should address the perceptions and needs of poultry raisers in different settings.