Publications by authors named "Suzanne Namusoke Kiwanuka"

12 Publications

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Research for universal health coverage: setting priorities for policy and systems research in Uganda.

Glob Health Action 2021 01;14(1):1956752

Department of Health Policy, Planning and Management, School of Public Health Makerere University Kampala Uganda, Uganda.

Background: There is international consensus on the need for countries to work towards achieving universal health coverage (UHC) whereby the population is given access to all appropriate promotive, preventive, curative and rehabilitative services at affordable cost. The World Health Organisation (2013) urges all countries to undertake research to customise UHC within national development agendas.

Objective: To describe the process used to prioritise UHC within the health systems research and development agenda in Uganda.

Methods: Two national consultative workshops were convened in May and August 2015 to develop a UHC research agenda in Uganda. The participants included multisector representatives from local, national, and international organisations. A participatory approach with structured deliberations and multi-voting techniques was used. Stakeholders' views were analysed thematically according to health systems building blocks, and multi-voting was used to assign priorities across themes and sub-themes. The priorities were further validated and disseminated at national health sector meetings.

Results: Of the 80 invited stakeholders, 57 (71.3%) attended. The expressed priorities were: 1) health workforce; 2) governance; 3) financing; 4) service delivery, and 5) community health. The participants also recommended crosscutting research themes to address the social determinants of health, multisectoral collaboration, and health system resilience to protect against external shocks and disease epidemics.

Conclusion: Discussions that capture the diverse perspectives of stakeholders provide a way of exploring UHC within health policy and systems development. In Uganda, attention should be paid to the principal challenges of mobilising financial and technical capabilities for research and strengthening the link between evidence generation and policy actions to achieve UHC.
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http://dx.doi.org/10.1080/16549716.2021.1956752DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8381970PMC
January 2021

Designing for Scale and taking scale to account: lessons from a community score card project in Uganda.

Int J Equity Health 2021 01 11;20(1):31. Epub 2021 Jan 11.

Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, 21205, Baltimore, MD, United States of America.

Background: Planning for the implementation of community scorecards (CSC) is an important, though seldom documented process. Makerere University School of Public Health (MakSPH) and Future Health Systems Consortium set out to develop and test a sustainable and scalable CSC model. This paper documents the process of planning and adapting the design of the CSC, incorporating key domains of the scalable model such as embeddedness, legitimacy, feasibility and ownership, challenges encountered in this process and how they were mitigated.

Methods: The CSC intervention comprised of five rounds of scoring in five sub counties and one town council of Kibuku district. Data was drawn from ten focus group discussions, seven key informant interviews with local and sub national leaders, and one reflection meeting with the project team from MakSPH. More data was abstracted from notes of six quarterly stakeholder meetings and six quarterly project meetings. Data was analyzed using a thematic approach, drawing constructs outlined in the project's theory of change.

Results: Embeddedness, legitimacy and ownership were promoted through aligning the model with existing processes and systems as well as the meaningful and strategic involvement of stakeholders and leaders at local and sub national level. The challenges encountered included limited technical capacity of stakeholders facilitating the CSC, poor functionality of existing community engagement platforms, and difficulty in promoting community participation without financial incentives. However, these challenges were mitigated through adjustments to the intervention design based on the feedback received.

Conclusion: Governments seeking to scale up CSCs and to take scale to account should keenly adapt existing models to the local implementation context with strategic and meaningful involvement of key legitimate local and sub national leaders in decision making during the design and implementation process. However, they should watch out for elite capture and develop mitigating strategies. Social accountability practitioners should document their planning and adaptive design efforts to share good practices and lessons learned. Enhancing local capacity to implement CSCs should be ensured through use of existing local structures and provision of technical support by external or local partners familiar with the skill until the local partners are competent.
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http://dx.doi.org/10.1186/s12939-020-01367-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7802338PMC
January 2021

Participatory monitoring and evaluation approaches that influence decision-making: lessons from a maternal and newborn study in Eastern Uganda.

Health Res Policy Syst 2017 Dec 28;15(Suppl 2):107. Epub 2017 Dec 28.

Department of International Health, Johns Hopkins University School of Public Health, Baltimore, MD, United States of America.

Background: The use of participatory monitoring and evaluation (M&E) approaches is important for guiding local decision-making, promoting the implementation of effective interventions and addressing emerging issues in the course of implementation. In this article, we explore how participatory M&E approaches helped to identify key design and implementation issues and how they influenced stakeholders' decision-making in eastern Uganda.

Method: The data for this paper is drawn from a retrospective reflection of various M&E approaches used in a maternal and newborn health project that was implemented in three districts in eastern Uganda. The methods included qualitative and quantitative M&E techniques such as  key informant interviews, formal surveys and supportive supervision, as well as participatory approaches, notably participatory impact pathway analysis.

Results: At the design stage, the M&E approaches were useful for identifying key local problems and feasible local solutions and informing the activities that were subsequently implemented. During the implementation phase, the M&E approaches provided evidence that informed decision-making and helped identify emerging issues, such as weak implementation by some village health teams, health facility constraints such as poor use of standard guidelines, lack of placenta disposal pits, inadequate fuel for the ambulance at some facilities, and poor care for low birth weight infants. Sharing this information with key stakeholders prompted them to take appropriate actions. For example, the sub-county leadership constructed placenta disposal pits, the district health officer provided fuel for ambulances, and health workers received refresher training and mentorship on how to care for newborns.

Conclusion: Diverse sources of information and perspectives can help researchers and decision-makers understand and adapt evidence to contexts for more effective interventions. Supporting districts to have crosscutting, routine information generating and sharing platforms that bring together stakeholders from different sectors is therefore crucial for the successful implementation of complex development interventions.
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http://dx.doi.org/10.1186/s12961-017-0274-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5751403PMC
December 2017

Persisting demand and supply gap for maternal and newborn care in eastern Uganda: a mixed-method cross-sectional study.

Reprod Health 2017 Oct 24;14(1):136. Epub 2017 Oct 24.

Department of Health Policy Planning and Management, Makerere University School of Public Health, Kampala, Uganda.

Background: The slow progress in reducing maternal and newborn death in low and middle-income countries is attributed to both demand and supply-side factors. This study assessed the changes in maternal and newborn services in health facilities as well as demand for maternal and newborn health services in Eastern Uganda.

Methods: The health assessment data were collected in August 2013 and September 2015 in the districts of Kamuli, Pallisa, and Kibuku. We purposively collected data on the availability of services from 40 health facilities that provided maternal and newborn services. In addition, we conducted 24 focus group discussions (FGDs) with women and men; and 18 key informant interviews (KIs) with health workers.

Results: On the supply side, most health facilities persistently lacked lifesaving medicines such as misoprostol, IV Ampicillin, IV Gentamycin, IV Metronidazole, Magnesium Sulphate, Ergometrine, Corticosteroids, ferrous Sulphate, Folic Acid, Combined ferrous, Benzyl penicillin, and Diazepam (IM or IV). Basic newborn equipment such as stethoscope, fetal scope, working baby scale, newborn suction devices, newborn resuscitation device, and thermometer were persistently not available in most of the health facilities. Binders for Kangaroo Mother Care, blanket to wrap newborn, baby warmer or heat lamp were persistently not available in at least 80% of the health facilities. Other equipment for the management of labor and abortions such as Manual vacuum aspirator for abortion care, blank partographs and vacuum extractor were not available in most of the health facilities including referral facilities at baseline and follow-up. On the demand side, the qualitative interviews exposed long distances and inadequate transport to the health facilities, inadequate information, poverty, and poor services at the health facilities as major factors that impede women to utilize/access maternal and newborn services.

Conclusion: There are distinct influences on both demand and supply side, which restrain both health care uptake and its quality. The frequent disparity between the health facility readiness to provide services and the women readiness to utilize them needs to be addressed as the country intensifies its efforts to reduce maternal and newborn deaths through boosting facility deliveries.
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http://dx.doi.org/10.1186/s12978-017-0402-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5655951PMC
October 2017

Effect of a participatory multisectoral maternal and newborn intervention on maternal health service utilization and newborn care practices: a quasi-experimental study in three rural Ugandan districts.

Glob Health Action 2017 Aug;10(sup4):1363506

a Department of Health Policy Planning and Management , Makerere University School of Public Health , Kampala , Uganda.

Background: The MANIFEST study in eastern Uganda employed a participatory multisectoral approach to reduce barriers to access to maternal and newborn care services.

Objectives: This study analyses the effect of the intervention on the utilization of maternal and newborn services and care practices.

Methods: The quasi-experimental pre- and post-comparison design had two main components: community mobilization and empowerment, and health provider capacity building. The primary outcomes were utilization of antenatal care (ANC), delivery and postnatal care, and newborn care practices. Baseline (n = 2237) and endline (n = 1946) data were collected from women of reproductive age. The  data was analysed using difference in differences (DiD) analysis and  logistic regression.

Results: The DiD results revealed an 8% difference in early ANC attendance (p < 0.01) and facility delivery (p < 0.01). Facility delivery increased from 66% to 73% in the intervention area, but remained unchanged in the comparison area (64% vs 63%, p < 0.01). The DiD results also demonstrated a 20% difference in clean cord care (p < 0.001) and an 8% difference in delayed bathing (p < 0.001). The intervention elements that predicted facility delivery were attending ANC four times [adjusted odds ratio (aOR) 1.42, 95% confidence interval (CI) 1.17-1.74] and saving for maternal health (aOR 2.11, 95% CI 1.39-3.21). Facility delivery and village health team (VHT) home visits were key predictors for clean cord care and skin-to-skin care.

Conclusions: The multisectoral approach had positive effects on early ANC attendance, facility deliveries and newborn care practices. Community resources such as VHTs and savings are crucial to maternal and newborn outcomes and should be supported. VHT-led health education should incorporate practical measures that enable families to save and access transport services to enhance adequate preparation for birth.
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http://dx.doi.org/10.1080/16549716.2017.1363506DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5645678PMC
August 2017

Characteristics of community savings groups in rural Eastern Uganda: opportunities for improving access to maternal health services.

Glob Health Action 2017 Aug;10(sup4):1347363

a Makerere University School of Public Health , Department of Health Policy Planning and Management , Kampala , Uganda.

Background: Rural populations in Uganda have limited access to formal financial Institutions, but a growing majority belong to saving groups. These saving groups could have the potential to improve household income and access to health services.

Objective: To understand organizational characteristics, benefits and challenges, of savings groups in rural Uganda.

Methods: This was a cross-sectional descriptive study that employed both quantitative and qualitative data collection techniques. Data on the characteristics of community-based savings groups (CBSGs) were collected from 247 CBSG leaders in the districts of Kamuli, Kibukuand Pallisa using self-administered open-ended questionnaires. To triangulate the findings, we conducted in-depth interviews with seven CBSG leaders. Descriptive quantitative and content analysis for qualitative data was undertaken respectively.

Results: Almost a quarter of the savings groups had 5-14 members and slightly more than half of the saving groups had 15-30 members. Ninety-three percent of the CBSGs indicated electing their management committees democratically to select the group leaders and held meetings at least once a week. Eighty-nine percent of the CBSGs had used metallic boxes to keep their money, while 10% of the CBSGs kept their money using mobile money and banks,respectively. The main reasons for the formation of CBSGs were to increase household income, developing the community and saving for emergencies. The most common challenges associated with CBSG management included high illiteracy (35%) among the leaders,irregular attendance of meetings (22%), and lack of training on management and leadership(19%). The qualitative findings agreed with the quantitative findings and served to triangulate the main results.

Conclusions: Saving groups in Uganda have the basic required structures; however, challenges exist in relation to training and management of the groups and their assets. The government and development partners should work together to provide technical support to the groups.
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http://dx.doi.org/10.1080/16549716.2017.1347363DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5645720PMC
August 2017

Effect of a participatory multisectoral maternal and newborn intervention on birth preparedness and knowledge of maternal and newborn danger signs among women in Eastern Uganda: a quasi-experiment study.

Glob Health Action 2017 08;10(sup4):1362826

a Department of Health Policy Planning and Management , Makerere University School of Public Health , Kampala , Uganda.

Background: Knowledge of obstetric danger signs and adequate birth preparedness (BP) are critical for improving maternal services utilization.

Objectives: This study assessed the effect of a participatory multi-sectoral maternal and newborn intervention on BP and knowledge of obstetric danger signs among women in Eastern Uganda.

Methods: The Maternal and Neonatal Implementation for Equitable Systems (MANIFEST) study was implemented in three districts from 2013 to 2015 using a quasi-experimental pre-post comparison design. Data were collected from women who delivered in the last 12 months. Difference-in-differences (DiD) and generalized linear modelling analysis were used to assess the effect of the intervention on BP practices and knowledge of obstetric danger signs.

Results: The overall BP practices increased after the intervention (DiD = 5, p < 0.05). The increase was significant in both intervention and comparison areas (7-39% vs. 7-36%, respectively), with a slightly higher increase in the intervention area. Individual savings, group savings, and identification of a transporter increased in both intervention and comparison area (7-69% vs. 10-64%, 0-11% vs. 0-5%, and 9-14% vs. 9-13%, respectively). The intervention significantly increased the knowledge of at least three obstetric danger signs (DiD = 31%) and knowledge of at least two newborn danger signs (DiD = 21%). Having knowledge of at least three BP components and attending community dialogue meetings increased the odds of BP practices and obstetric danger signs' knowledge, respectively. Village health teams' home visits, intervention area residence, and being in the 25+ age group increased the odds of both BP practices and obstetric danger signs' knowledge.

Conclusions: The intervention resulted in a modest increase in BP practices and knowledge of obstetric danger signs. Multiple strategies targeting women, in particular the adolescent group, are needed to promote behavior change for improved BP and knowledge of obstetric danger signs.
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http://dx.doi.org/10.1080/16549716.2017.1362826DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5645681PMC
August 2017

Maternal and neonatal implementation for equitable systems. A study design paper.

Glob Health Action 2017 Aug;10(sup4):1346925

a Makerere University School of Public Health (MakSPH) , Makerere University , Kampala , Uganda.

Background: Evidence on effective ways of improving maternal and neonatal health outcomes is widely available. The challenge that most low-income countries grapple with is implementation at scale and sustainability.

Objectives: The study aimed at improving access to quality maternal and neonatal health services in a sustainable manner by using a participatory action research approach.

Methods:  The  study consisted of a quasi-experimental design, with a participatory action research approach to implementation in three rural districts (Pallisa, Kibuku and Kamuli) in Eastern Uganda. The intervention had two main components; namely, community empowerment for comprehensive birth preparedness, and health provider and management capacity-building. We collected data using both quantitative and qualitative methods using household and facility-level structured surveys, record reviews, key informant interviews and focus group discussions. We purposively selected the participants for the qualitative data collection, while for the surveys we interviewed all eligible participants in the sampled households and health facilities. Descriptive statistics were used to describe the data, while the difference in difference analysis was used to measure the effect of the intervention. Qualitative data were analysed using thematic analysis.

Conclusions: This study was implemented to generate evidence on how to increase access to quality maternal and newborn health services in a sustainable manner using a multisectoral participatory  approach.
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http://dx.doi.org/10.1080/16549716.2017.1346925DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5645657PMC
August 2017

Working with community health workers to improve maternal and newborn health outcomes: implementation and scale-up lessons from eastern Uganda.

Glob Health Action 2017 Aug;10(sup4):1345495

a Makerere University , School of Public Health (MakSPH) , Kampala , Uganda.

Background: Preventable maternal and newborn deaths can be averted through simple evidence-based interventions, such as the use of community health workers (CHWs), also known in Uganda as village health teams. However, the CHW strategy faces implementation challenges regarding training packages, supervision, and motivation.

Objectives: This paper explores knowledge levels of CHWs, describes the coverage of home visits, and shares lessons learnt from setting up and implementing the CHW strategy.

Methods: The CHWs were trained to conduct four home visits: two during pregnancy and two after delivery. The aim of the visits was to promote birth preparedness and utilization of maternal and newborn health (MNH) services. Mixed methods of data collection were employed. Quantitative data were analyzed using Stata version 13.0 to determine the level and predictors of CHW knowledge of MNH. Qualitative data from 10 key informants and 15 CHW interviews were thematically analyzed to assess the implementation experiences.

Results: CHWs' knowledge of MNH improved from 41.3% to 77.4% after training, and to 79.9% 1 year post-training. However, knowledge of newborn danger signs declined from 85.5% after training to 58.9% 1 year later. The main predictors of CHW knowledge were age (≥ 35 years) and post-primary level of education. The level of coverage of at least one CHW visit to pregnant and newly delivered mothers was 57.3%. Notably, CHW reports complemented the facility-based health information. CHWs formed associations, which improved teamwork, reporting, and general performance, and thus maintained low dropout rates at 3.6%. Challenges included dissatisfaction with the quarterly transport refund of 6 USD and lack of means of transportation such as bicycles.

Conclusions: CHWs are an important resource in community-based health information and improving demand for MNH services. However, the CHW training and supervision models require strengthening for improved performance. Local solutions regarding CHW motivation are necessary for sustainability.
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http://dx.doi.org/10.1080/16549716.2017.1345495DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5786312PMC
August 2017

Balancing the cost of leaving with the cost of living: drivers of long-term retention of health workers: an explorative study in three rural districts in Eastern Uganda.

Glob Health Action 2017 Aug;10(sup4):1345494

a Makerere University School of Public Health (MakSPH), Department of Health Policy Planning and Management , Makerere University , Kampala , Uganda.

Background: Health worker retention in rural and underserved areas remains a persisting problem in many low and middle income countries, and this directly affects the quality of health services offered.

Objective: This paper explores the drivers of long-term retention and describes health worker coping mechanisms in rural Uganda.

Methods: A descriptive qualitative study explored the factors that motivated health workers to stay, in three rural districts of Uganda: Kamuli, Pallisa, and Kibuku. In-depth interviews conducted among health workers who have been retained for at least 10 years explored factors motivating the health workers to stay within the district, opportunities, and the benefits of staying.

Results: Twenty-one health workers participated. Ten of them male and 11 female with the age range of 33-51 years. The mean duration of stay among the participants was 13, 15, and 26 years for Kamuli, Kibuku, and Pallisa respectively. Long-term retention was related to personal factors, such as having family ties, community ties, and opportunities to invest. The decentralization policy and pension benefits also kept workers in place. Opportunities for promotion or leadership motivated long stay only if they came with financial benefits. Workload reportedly increased over the years, but staffing and emoluments had not increased. Multiple job, family support, and community support helped health workers cope with the costs of living, and holding a secure pensionable government job was valued more highly than seeking uncertain job opportunities elsewhere.

Conclusion: The interplay between the costs of leaving and the benefit of staying is demonstrated. Family proximity, community ties, job security, and pension enhance staying, while higher costs of living and an unpredictable employment market make leaving risky. Health workers should be able to access investment opportunities in order to cope with inadequate remuneration. Promotions and leadership opportunities only motivate if accompanied by financial benefits.
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http://dx.doi.org/10.1080/16549716.2017.1345494DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5645687PMC
August 2017

Effect of support supervision on maternal and newborn health services and practices in Rural Eastern Uganda.

Glob Health Action 2017 Aug;10(sup4):1345496

a Department of Health Policy, Planning and Management , Makerere University School of Public Health , Kampala , Uganda.

Background: Support supervision is one of the strategies used to check the quality of services provided at health facilities. From 2013 to 2015, Makerere University School of Public Health strengthened support supervision in the district of Kibuku, Kamuli and Pallisa in Eastern Uganda to improve the quality of maternal and newborn services.

Objective: This article assesses quality improvements in maternal and newborn care services and practices during this period.

Methods: District management teams were trained for two days on how to conduct the supportive supervision. Teams were then allocated particular facilities, which they consistently visited every quarter. During each visit, teams scored the performance of each facility based on checklists; feedback and corrective actions were implemented. Support supervision focused on maternal health services, newborn care services, human resources, laboratory services, availability of Information, education and communication materials and infrastructure. Support supervision reports and checklists from a total of 28 health facilities, each with at least three support supervision visits, were analyzed for this study and 20 key-informant interviews conducted.

Results: There was noticeable improvement in maternal and newborn services. For instance, across the first, second and third quarters, availability of parenteral oxytocin increased from 57% to 75% and then to 82%. Removal of retained products increased from 14% to 50% to 54%, respectively. There was perceived improvement in the use of standards and guidelines for emergency obstetric care and quality of care provided. Qualitatively, three themes were identified that promote the success of supportive supervision: changes in the support supervision style, changes in the adherence to clinical standards and guidelines, and multi-stakeholder engagement.

Conclusion: Support supervision helped district health managers to identify and address maternal and newborn service-delivery gaps. However, issues beyond the jurisdiction of district health managers and facility managers may require additional interventions beyond supportive supervision.
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http://dx.doi.org/10.1080/16549716.2017.1345496DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5645662PMC
August 2017

A cascade model of mentorship for frontline health workers in rural health facilities in Eastern Uganda: processes, achievements and lessons.

Glob Health Action 2017 Aug;10(sup4):1345497

b Department of Obstetrics and Gynaecology , Mulago National Referral Hospital , Kampala, Uganda.

Background: There is increasing demand for trainers to shift from traditional didactic training to innovative approaches that are more results-oriented. Mentorship is one such approach that could bridge the clinical knowledge gap among health workers.

Objectives: This paper describes the experiences of an attempt to improve health-worker performance in maternal and newborn health in three rural districts through a mentoring process using the cascade model. The paper further highlights achievements and lessons learnt during implementation of the cascade model.

Methods: The cascade model started with initial training of health workers from three districts of Pallisa, Kibuku and Kamuli from where potential local mentors were selected for further training and mentorship by central mentors. These local mentors then went on to conduct mentorship visits supported by the external mentors. The mentorship process concentrated on partograph use, newborn resuscitation, prevention and management of Post-Partum Haemorrhage (PPH), including active management of third stage of labour, preeclampsia management and management of the sick newborn. Data for this paper was obtained from key informant interviews with district-level managers and local mentors.

Results: Mentorship improved several aspects of health-care delivery, ranging from improved competencies and responsiveness to emergencies and health-worker professionalism. In addition, due to better district leadership for Maternal and Newborn Health (MNH), there were improved supplies/medicine availability, team work and innovative local problem-solving approaches. Health workers were ultimately empowered to perform better.

Conclusions: The study demonstrated that it is possible to improve the competencies of frontline health workers through performance enhancement for MNH services using locally built capacity in clinical mentorship for Emergency Obstetric and Newborn Care (EmONC). The cascade mentoring process needed strong external mentorship support at the start to ensure improved capacity among local mentors to provide mentorship among local district staff.
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http://dx.doi.org/10.1080/16549716.2017.1345497DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5645691PMC
August 2017
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