Publications by authors named "Theresa Ryckman"

11 Publications

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COVID-19 in the California State Prison System: an Observational Study of Decarceration, Ongoing Risks, and Risk Factors.

J Gen Intern Med 2021 Jul 21. Epub 2021 Jul 21.

Stanford Health Policy and the Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA.

Background: Correctional institutions nationwide are seeking to mitigate COVID-19-related risks.

Objective: To quantify changes to California's prison population since the pandemic began and identify risk factors for COVID-19 infection.

Design: For California state prisons (March 1-October 10, 2020), we described residents' demographic characteristics, health status, COVID-19 risk scores, room occupancy, and labor participation. We used Cox proportional hazard models to estimate the association between rates of COVID-19 infection and room occupancy and out-of-room labor, respectively.

Participants: Residents of California state prisons.

Main Measures: Changes in the incarcerated population's size, composition, housing, and activities. For the risk factor analysis, the exposure variables were room type (cells vs. dormitories) and labor participation (any room occupant participating in the prior 2 weeks) and the outcome variable was incident COVID-19 case rates.

Key Results: The incarcerated population decreased 19.1% (119,401 to 96,623) during the study period. On October 10, 2020, 11.5% of residents were aged ≥60, 18.3% had high COVID-19 risk scores, 31.0% participated in out-of-room labor, and 14.8% lived in rooms with ≥10 occupants. Nearly 40% of residents with high COVID-19 risk scores lived in dormitories. In 9 prisons with major outbreaks (6,928 rooms; 21,750 residents), dormitory residents had higher infection rates than cell residents (adjusted hazard ratio [AHR], 2.51 95% CI, 2.25-2.80) and residents of rooms with labor participation had higher rates than residents of other rooms (AHR, 1.56; 95% CI, 1.39-1.74).

Conclusion: Despite reductions in room occupancy and mixing, California prisons still house many medically vulnerable residents in risky settings. Reducing risks further requires a combination of strategies, including rehousing, decarceration, and vaccination.
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http://dx.doi.org/10.1007/s11606-021-07022-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8294831PMC
July 2021

Covid-19 in the California State Prison System: An Observational Study of Decarceration, Ongoing Risks, and Risk Factors.

medRxiv 2021 Mar 8. Epub 2021 Mar 8.

Stanford Health Policy and the Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA.

Background: Correctional institutions nationwide are seeking to mitigate Covid-19-related risks.

Objective: To quantify changes to California's prison population since the pandemic began and identify risk factors for Covid-19 infection.

Design: We described residents' demographic characteristics, health status, Covid-19 risk scores, room occupancy, and labor participation. We used Cox proportional hazard models to estimate the association between rates of Covid-19 infection and room occupancy and out-of-room labor, respectively.

Setting: California state prisons (March 1-October 10, 2020).

Participants: Residents of California state prisons.

Measurements: Changes in the incarcerated population's size, composition, housing, and activities. For the risk factor analysis, the exposure variables were room type (cells vs dormitories) and labor participation (any room occupant participating in the prior 2 weeks) and the outcome variable was incident Covid-19 case rates.

Results: The incarcerated population decreased 19.1% (119,401 to 96,623) during the study period.On October 10, 2020, 11.5% of residents were aged ≥60, 18.3% had high Covid-19 risk scores, 31.0% participated in out-of-room labor, and 14.8% lived in rooms with ≥10 occupants. Nearly 40% of residents with high Covid-19 risk scores lived in dormitories. In 9 prisons with major outbreaks (6,928 rooms; 21,750 residents), dormitory residents had higher infection rates than cell residents (adjusted hazard ratio [AHR], 2.51 95%CI, 2.25-2.80) and residents of rooms with labor participation had higher rates than residents of other rooms (AHR, 1.56; 95%CI, 1.39-1.74).

Limitations: Inability to measure density of residents' living conditions or contact networks among residents and staff.

Conclusion: Despite reductions in room occupancy and mixing, California prisons still house many medically vulnerable residents in risky settings. Reducing risks further requires a combination of strategies, including rehousing, decarceration, and vaccination.

Funding Sources: Horowitz Family Foundation; National Institute on Drug Abuse; National Science Foundation Graduate Research Fellowship; Open Society Foundations.
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http://dx.doi.org/10.1101/2021.03.04.21252942DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7987024PMC
March 2021

Affordability of nutritious foods for complementary feeding in South Asia.

Nutr Rev 2021 03;79(Suppl 1):52-68

United Nations Children's Fund, Regional Office for South Asia, Kathmandu, Nepal.

The high prevalence of stunting and micronutrient deficiencies among children in South Asia has lifelong health, educational, and economic consequences. For children aged 6-23 months, undernutrition is influenced by inadequate intake of complementary foods containing nutrients critical for growth and development. The affordability of nutrients lacking in young children's diets in Bangladesh, India, and Pakistan was assessed in this study. Using data from nutrient gap assessments and household surveys, household food expenditures were compared with the cost of purchasing foods that could fill nutrient gaps. In all 3 countries, there are multiple affordable sources of vitamin A (orange-fleshed vegetables, dark leafy greens, liver), vitamin B12 (liver, fish, milk), and folate (dark leafy greens, liver, legumes, okra); few affordable sources of iron and calcium (dark leafy greens); and no affordable sources of zinc. Affordability of animal-source protein varies, with several options in Pakistan (fish, chicken, eggs, beef) and India (fish, eggs, milk) but few in Bangladesh (eggs). Approaches to reduce prices, enhance household production, or increase incomes are needed to improve affordability.
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http://dx.doi.org/10.1093/nutrit/nuaa139DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7948078PMC
March 2021

Affordability of nutritious foods for complementary feeding in Eastern and Southern Africa.

Nutr Rev 2021 03;79(Suppl 1):35-51

United Nations Children's Fund, Regional Office for Eastern and Southern Africa, Nairobi, Kenya.

Low intake of diverse complementary foods causes critical nutrient gaps in the diets of young children. Inadequate nutrient intake in the first 2 years of life can lead to poor health, educational, and economic outcomes. In this study, the extent to which food affordability is a barrier to consumption of several nutrients critical for child growth and development was examined in Ethiopia, Mozambique, South Africa, Tanzania, Uganda, and Zambia. Drawing upon data from nutrient gap assessments, household surveys, and food composition tables, current consumption levels were assessed, the cost of purchasing key nutritious foods that could fill likely nutrient gaps was calculated, and these costs were compared with current household food expenditure. Vitamin A is affordable for most households (via dark leafy greens, orange-fleshed vegetables, and liver) but only a few foods (fish, legumes, dairy, dark leafy greens, liver) are affordable sources of iron, animal-source protein, or calcium, and only in some countries. Zinc is ubiquitously unaffordable. For unaffordable nutrients, approaches to reduce prices, enhance household production, or increase household resources for nutritious foods are needed.
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http://dx.doi.org/10.1093/nutrit/nuaa137DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7948081PMC
March 2021

Methods for Model Calibration under High Uncertainty: Modeling Cholera in Bangladesh.

Med Decis Making 2020 07 8;40(5):693-709. Epub 2020 Jul 8.

Center for Health Policy and Center for Primary Care & Outcomes Research, Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA.

Published data on a disease do not always correspond directly to the parameters needed to simulate natural history. Several calibration methods have been applied to computer-based disease models to extract needed parameters that make a model's output consistent with available data. To assess 3 calibration methods and evaluate their performance in a real-world application. We calibrated a model of cholera natural history in Bangladesh, where a lack of active surveillance biases available data. We built a cohort state-transition cholera natural history model that includes case hospitalization to reflect the passive surveillance data-generating process. We applied 3 calibration techniques: incremental mixture importance sampling, sampling importance resampling, and random search with rejection sampling. We adapted these techniques to the context of wide prior uncertainty and many degrees of freedom. We evaluated the resulting posterior parameter distributions using a range of metrics and compared predicted cholera burden estimates. All 3 calibration techniques produced posterior distributions with a higher likelihood and better fit to calibration targets as compared with prior distributions. Incremental mixture importance sampling resulted in the highest likelihood and largest number of unique parameter sets to better inform joint parameter uncertainty. Compared with naïve uncalibrated parameter sets, calibrated models of cholera in Bangladesh project substantially more cases, many of which are not detected by passive surveillance, and fewer deaths. Calibration cannot completely overcome poor data quality, which can leave some parameters less well informed than others. Calibration techniques may perform differently under different circumstances. . Incremental mixture importance sampling, when adapted to the context of high uncertainty, performs well. By accounting for biases in data, calibration can improve model projections of disease burden.
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http://dx.doi.org/10.1177/0272989X20938683DOI Listing
July 2020

Impact of Feed the Future initiative on nutrition in children aged less than 5 years in sub-Saharan Africa: difference-in-differences analysis.

BMJ 2019 Dec 11;367:l6540. Epub 2019 Dec 11.

Center for Health Policy and the Center for Primary Care and Outcomes Research, Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA.

Objective: To evaluate the impact of the US government's Feed the Future initiative on nutrition outcomes in children younger than 5 years in sub-Saharan Africa.

Design: Difference-in-differences quasi-experimental approach.

Setting: Households in 33 low and lower middle income countries in sub-Saharan Africa.

Population: 883 309 children aged less than 5 years with weight, height, and age recorded in 118 surveys conducted in 33 countries between 2000 and 2017: 388 052 children were from Feed the Future countries and 495 257 were from non-Feed the Future countries.

Main Outcome Measures: A difference-in-differences approach was used to compare outcomes among children in intervention countries after implementation of the initiative with children before its introduction and children in non-intervention countries, controlling for relevant covariates, time invariant national differences, and time trends. The primary outcome was stunting (height for age >2 standard deviations below a reference median), a key indicator of undernutrition in children. Secondary outcomes were wasting (low weight for height) and underweight (low weight for age).

Results: Across all years and countries, 38.3% of children in the study sample were stunted, 8.9% showed wasting, and 21.3% were underweight. In the first six years of Feed the Future's implementation, children in 12 countries with the initiative exhibited a 3.9 percentage point (95% confidence interval 2.4 to 5.5) greater decline in stunting, a 1.1 percentage point (0.1 to 2.1) greater decline in wasting, and a 2.8 percentage point (1.6 to 4.0) greater decline in underweight levels compared with children in 21 countries without the initiative and compared with trends in undernutrition before Feed the Future was launched. These decreases translate to around two million fewer stunted and underweight children aged less than 5 years and around a half million fewer children with wasting. For context, about 22 million children were stunted, 11 million children were underweight, and four million children were wasted in the Feed the Future countries at baseline.

Conclusions: Feed the Future's activities were closely linked to notable improvements in stunting and underweight levels and moderate improvements in wasting in children younger than 5 years. These findings highlight the effectiveness of this large, country tailored initiative focused on agriculture and food security and have important implications for the future of this and other nutrition interventions worldwide.
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http://dx.doi.org/10.1136/bmj.l6540DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7190055PMC
December 2019

Gavi's Transition Policy: Moving From Development Assistance To Domestic Financing Of Immunization Programs.

Health Aff (Millwood) 2016 Feb;35(2):250-8

Paul Wilson is an assistant professor at the Mailman School of Public Health, Columbia University, in New York City.

Gavi, the Vaccine Alliance, was created in 2000 to accelerate the introduction of new and underused vaccines in lower-income countries. The period 2000-15 was marked by the rapid uptake of new vaccines in more than seventy countries eligible for Gavi support. To stay focused on the poorest countries, Gavi's support phases out after countries' gross national income per capita surpasses a set threshold, which requires governments to assume responsibility for the continued financing of vaccines introduced with Gavi support. Gavi's funding will end in the period 2016-20 for nineteen countries that have exceeded the eligibility threshold. To avoid disrupting lifesaving immunization programs and to ensure the long-term sustainable impact of Gavi's investments, it is vital that governments succeed in transitioning from development assistance to domestic financing of immunization programs. This article discusses some of the challenges facing countries currently transitioning out of Gavi support, how Gavi's policies have evolved to help manage the risks involved in this process, and the lessons learned from this experience.
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http://dx.doi.org/10.1377/hlthaff.2015.1079DOI Listing
February 2016

Funding AIDS programmes in the era of shared responsibility: an analysis of domestic spending in 12 low-income and middle-income countries.

Lancet Glob Health 2015 Jan;3(1):e52-61

Results for Development Institute, Washington, DC, USA. Electronic address:

Background: As the incomes of many AIDS-burdened countries grow and donors' budgets for helping to fight the disease tighten, national governments and external funding partners increasingly face the following question: what is the capacity of countries that are highly affected by AIDS to finance their responses from domestic sources, and how might this affect the level of donor support? In this study, we attempt to answer this question.

Methods: We propose metrics to estimate domestic AIDS financing, using methods related to national prioritisation of health spending, disease burden, and economic growth. We apply these metrics to 12 countries in sub-Saharan Africa with a high prevalence of HIV/AIDS, generating scenarios of possible future domestic expenditure. We compare the results with total AIDS financing requirements to calculate the size of the resulting funding gaps and implications for donors.

Findings: Nearly all 12 countries studied fall short of the proposed expenditure benchmarks. If they met these benchmarks fully, domestic spending on AIDS would increase by 2·5 times, from US$2·1 billion to $5·1 billion annually, covering 64% of estimated future funding requirements and leaving a gap of around a third of the total $7·9 billion needed. Although upper-middle-income countries, such as Botswana, Namibia, and South Africa, would become financially self-reliant, lower-income countries, such as Mozambique and Ethiopia, would remain heavily dependent on donor funds.

Interpretation: The proposed metrics could be useful to stimulate further analysis and discussion around domestic spending on AIDS and corresponding donor contributions, and to structure financial agreements between recipient country governments and donors. Coupled with improved resource tracking, such metrics could enhance transparency and accountability for efficient use of money and maximise the effect of available funding to prevent HIV infections and save lives.

Funding: US Centers for Disease Control and Prevention.
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http://dx.doi.org/10.1016/S2214-109X(14)70342-0DOI Listing
January 2015

Overcoming challenges to sustainable immunization financing: early experiences from GAVI graduating countries.

Health Policy Plan 2015 Mar 8;30(2):197-205. Epub 2014 Feb 8.

Consultant to Results for Development Institute, Washington, DC 20005, USA, Results for Development Institute, Washington, DC 20005, USA, World Health Organization, 1211 Geneva, Switzerland, Consultant to World Health Organization, 1211 Geneva, Switzerland, GAVI Alliance, 1202 Geneva, Switzerland.

Over the 5-year period ending in 2018, 16 countries with a combined birth cohort of over 6 million infants requiring life-saving immunizations are scheduled to transition (graduate) from outside financial and technical support for a number of their essential vaccines. This support has been provided over the past decade by the GAVI Alliance. Will these 16 countries be able to continue to sustain these vaccination efforts? To address this issue, GAVI and its partners are supporting transition planning, entailing country assessments of readiness to graduate and intensive dialogue with national officials to ensure a smooth transition process. This approach was piloted in Bhutan, Republic of Congo, Georgia, Moldova and Mongolia in 2012. The pilot showed that graduating countries are highly heterogeneous in their capacity to assume responsibility for their immunization programmes. Although all possess certain strengths, each country displayed weaknesses in some of the following areas: budgeting for vaccine purchase, national procurement practices, performance of national regulatory agencies, and technical capacity for vaccine planning and advocacy. The 2012 pilot experience further demonstrated the value of transition planning processes and tools. As a result, GAVI has decided to continue with transition planning in 2013 and beyond. As the graduation process advances, GAVI and graduating countries should continue to contribute to global collective thinking about how developing countries can successfully end their dependence on donor aid and achieve self-sufficiency.
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http://dx.doi.org/10.1093/heapol/czu003DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4325534PMC
March 2015
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