Duke Institute for Health Innovation

High-deductible health plan (HDHP) members face relatively high out-of-pocket (OOP) costs for urgent care, high-acuity care, and secondary prevention. These costs could affect the timing of cardiometabolic disease diagnosis. To determine whether HDHPs are associated with delays in diabetes diagnosis and increases in health care costs in the period surrounding new diagnoses. Segmented survival with control group and pre-post with control group. Members aged 18 to 64years without diabetes at the beginning of the pre-index period. Characteristics of interest for stratified analyses comprised sex, income, and race/ethnicity. Employer-mandated transition from low-deductible health plan to HDHP. Time to first diabetes diagnosis; and total and OOP medical costs in the peri-diagnosis period (from 30days before to 90days after first diabetes diagnosis). In this sample of 346,492 HDHP members and 346,492 matched and weighted controls, the mean (SD) age was 42.3 (13.0) years, and 48.5% were women. The overall and female HDHP groups experienced delays in diabetes diagnosis in the post- versus pre-index period (adjusted hazard ratio, aHR: 0.93 [95% CI 0.88, 0.99] and 0.91 [0.83, 0.99], respectively), compared with controls. These hazard ratios corresponded to delays of 1.7 and 2.1months compared with median diagnosed control patients. Other HDHP subgroups did not have statistically significant delays. HDHP group members newly diagnosed with diabetes had relative post- versus pre-index increases in total and OOP peri-diagnosis medical costs of 20% (95%CI1%, 39%) and 51% (95%CI33%, 60%), respectively, versus controls. HDHP enrollment was associated with delayed diabetes diagnosis and substantially increased peri-diagnosis total and OOP medical costs. Female HDHP members might be especially at risk. Policymakers should consider reducing OOP costs for key health care services associated with diagnosing diabetes.

Training the next generation of leaders in global surgery includes equipping learners with skills in collaboration, research, policy, and health system management. Since 2021, the Duke Global Health Institute and the University of Global Health Equity in Rwanda have co-taught a course in Global Surgical Care for learners from around the world. This review discusses our use of the Lancet Commission on Global Surgery (LCoGS), exploring it as both a foundational reference text and an organizing framework for teaching core issues in global surgical care. The LCoGS guides the selection of important topics including surgical disease burden, infrastructure, workforce, and economics. Through the semester, students use these concepts in team-based applications, culminating in the development of a National Surgical, Obstetric, and Anaesthesia Plan (NSOAP) for an assigned country. The LCoGS provides a valuable foundation for teaching global surgical priorities and analytic approaches and provides guidance to support advocacy, ethics, and contextualized implementation initiatives for training emerging global surgical leaders.

The present study aimed to assess the viability of Social Skills Training through RPGs during the SARS-CoV-2 pandemic, employing qualitative discourse analysis of residents. Focus groups were conducted with a convenience sample of psychiatry residents who volunteered to participate in the RPG-based training. Eleven residents took part in video conference focus groups, with one researcher acting as a non-participant observer. Over a period of 4 months, residents engaged in weekly 3-h sessions structured around five fundamental steps: rapport building, task discussions, goal setting, gaming, and feedback. Results indicate positive impacts on group dynamics, communication skills, cooperation, assertiveness, empathy, mental health, and quality of life. However, given the exploratory nature of this study, further research incorporating pre- and post-intervention assessments is warranted to thoroughly evaluate the intervention’s effectiveness.

Reciprocal innovation, a model of sustained, multidirectional exchange in which health strategies are adapted, revisited, and refined across contexts, offers a compelling framework to rethink how implementation science can support global health equity by enabling dynamic, multidirectional learning across different contexts. Drawing on the EXTRA-CVD trial, a nurse-led cardiovascular disease prevention intervention designed to extend the HIV treatment cascade in United States (U.S.) HIV clinics, which adapted strategies informed by implementation research in Kenya and the U.S. Veterans Affairs health system, this perspective examines how reciprocal innovation can begin to emerge within existing research structures, as well as where opportunities for deeper exchange remain limited. We identify four operational domains of reciprocal innovation: care delivery strategies, end-user engagement, research methodologies, and research leadership and partnership. Across these domains, we describe how cross-context learning shaped intervention adaptation and site-level implementation in EXTRA-CVD, as well as missed opportunities where more intentional feedback, shared leadership, and methodological exchange could have strengthened multidirectional learning. Taken together, this work highlights both the potential and the practical challenges of reciprocal innovation in implementation research, emphasizing its role in moving beyond unidirectional knowledge transfer toward iterative, context-responsive learning. By embedding structures for iterative feedback, equity-centered governance, and multidirectional learning systems within research and implementation systems, future global partnerships can foster more inclusive, responsive, and sustainable health interventions.

After the expansion of the World Health Organization's guidelines on eligibility for the seasonal malaria chemoprevention (SMC), the government of Kenya prepared to implement SMC for a first time in Turkana Central Subcounty in 2024. To inform the design of SMC, we conducted a baseline qualitative and quantitative study. Using stratified cluster sampling, we enrolled 198 households with children of ages 6 months to 5 years and tested all individuals six months and older using a rapid diagnostic test (RDT) and polymerase chain reaction (PCR) for Plasmodium falciparum. We performed 78 key informant interviews; 31 focus group discussions with community health workers, elders, and caretakers of children; and 60 in-depth interviews with caretakers. Prevalence of P. falciparum infection was 21% (9-42%) by RDT and 21% (11-38%) by PCR. Prevalence varied across villages, with the highest positivity of 73% by PCR. Although SMC was perceived positively, the identified challenges included physical access (households far from village centers, pastoralists, children living in the streets), stigma (children living with disabilities, households with members struggling with alcohol use), and acceptability (traditionalists, highly educated households). Despite the high malaria burden in the region, SMC may be a feasible approach to reduce its burden and transmission. However, implementation of SMC should be tailored, combining centralized distribution with door-to-door delivery and outreach to pastoralists and people living in the interior. Using existing grassroots structures, such as pastoralist leadership structures and religious and group leaders, and intensive mobilization will be critical for success of this intervention.

<h2>Abstract</h2><h3>Objectives</h3> This pilot study sought to examine the distribution of circulating adenovirus types among humans and other animals in Pakistan. <h3>Methods</h3> Patients with influenza-like illness or pneumonia at seven hospitals were enrolled and sampled (oropharyngeal or nasopharyngeal swabs), and their epidemiological data were collected. Concomitantly, livestock with respiratory symptoms in live bird markets and farms were also sampled. These specimens were screened for evidence of adenovirus infection. <h3>Results</h3> Of 1705 total samples, 96 (8.8%) of 1084 humans and 15 (4%) of 385 poultry had molecular evidence of adenovirus. Infection in humans was significantly associated with wheezing, coughing, fever, and sore throat, and prevalence was greatest among participants residing outside Punjab. Genetic sequencing identified co-circulation of human-like adenovirus (HAdV-7) and HAdV-3 strains among humans. Further sequencing identified HAdV-C1, HAdV-5, HAdV-89, HAdV-12, and HAdV-56. Bovine adenovirus 2 was unexpectedly detected in a human nasal swab. Among poultry, fowl aviadenovirus (FAdV)-4 and FAdV-11 were identified. <h3>Conclusions</h3> Compared with other studies, there was a relatively high prevalence of adenoviruses among sick humans and poultry, with the unusual discovery of bovine adenovirus in a sick human's airway. There was considerable diversity among detected adenovirus strains. Given periodic adenovirus outbreaks in Pakistan, monitoring types in respiratory illness is key.

Globally, most farms are smaller than 10 hectares. Land use by these smallholder farmers in agricultural frontiers is crucial to conservation, food security, and exposure to infectious diseases. However, solely survey-based land use studies miss the fine scale movements that collectively form an individual’s land use and thus environmental exposures, particularly in fragmented landscapes. We applied movement ecology-based approaches with GPS and survey data to investigate how sociodemographic variables corresponded with land use among farmers living adjacent to Marojejy National Park in northeastern Madagascar. Our data on 902 individuals spanning 3 years revealed striking differences in land use by gender and socioeconomic status. Men traversed 65% (95% CI [51%, 82%]) more area and spent 30% less time (95% CI [20, 41%]) in the village than women. Socioeconomic status, educational attainment, and having young children covaried with time spent in secondary forests where vanilla is grown, swidden areas where slash-and-burn farming methods are used, and the national park. By revealing the extent to which social and demographic variables predict individual movement patterns, our work identifies targets for addressing emerging diseases and health disparities. The GPS and analytical approaches developed here can be applied elsewhere to provide policy insights and to understand variation across human-ecological systems.Supplementary InformationThe online version contains supplementary material available at 10.1038/s41598-026-40592-6.

BackgroundStepped wedge cluster randomized trials (SW-CRTs) have historically been analyzed using immediate treatment (IT) models, which assume the effect of the treatment is immediate after treatment initiation and subsequently remains constant over time. However, recent research has shown that this assumption can lead to severely misleading results if treatment effects vary with exposure time, i.e., time since the intervention started. Models that account for time-varying treatment effects, such as the exposure time indicator (ETI) model, allow researchers to target estimands such as the time-averaged treatment effect (TATE) over an interval of exposure time, or the point treatment effect (PTE) representing a treatment contrast at one time point. However, this increased flexibility results in reduced power.MethodsIn this paper, we use public power calculation software and simulation to characterize factors affecting SW-CRT power. Key elements include choice of estimand, study design considerations, and analysis model selection.ResultsFor common SW-CRT designs, the sample size (clusters per sequence or individuals per cluster-period) must be increased substantially, commonly by a factor of 1.5 to 3, but often by much more, to maintain 90% power when switching from an IT model to an ETI model (targeting the TATE over the study). However, the inflation factor is lower for TATE estimands over shorter periods that exclude longer exposure times. In general, SW-CRT designs (including the “staircase” variant) have much greater power for estimating “short-term effects” relative to “long-term effects.” For an ETI model targeting a TATE estimand, substantial power can be gained by adding time points to the start of the study or increasing baseline sample size, but surprisingly, little power is gained from adding time points to the end of the study. More restrictive choices for modeling the exposure time or calendar time trends (e.g., splines or linear terms) have little effect on power for TATE estimands but increases power for PTE estimands. If the effect curve is constant after a washout period, a “delayed constant treatment” model that uses exposure time indicators during the washout period but assumes a constant effect thereafter can slightly increase power relative to an IT model that discards washout period data.