African-American/Black and Latino/Hispanic persons living with HIV/AIDS  are under-represented in HIV/AIDS medical studies (HAMS). A crucial entry point into HAMS is screening, but PLHA of color face serious barriers to screening compared to Whites. Recently we evaluated a social/behavioral intervention that substantially increased rates of HAMS screening among PLHA of color. Yet very little is known about the actual screening experience for these under-represented subgroups. Thus, the objectives of the present study were to explore participants’ motivations for and experiences of HAMS screening.A total of 186 participants in the larger study’s intervention arm were screened for HAMS, 35 of whom also participated in qualitative interviews. Participants engaged in a structured interview about the screening experience at 4- and 12- months post-baseline . Further, from a qualitative data set we purposively selected a set of three case studies to contextualize and enrich quantitative findings on screening experiences.The screening experience was overwhelmingly positive. Almost all participants reported being treated with dignity and respect, did not feel they were being treated like a “guinea pig,” and experienced a high level of trust in the setting and the screener, with no gender or racial/ethnic differences, and no differences based on whether participants were found eligible for HAMS during screening. A number of areas where screening could be improved were also identified.Despite the complex barriers PLHA of color experience to screening for HAMS, the experience of screening was positive. Moreover, HAMS screening experiences were positive regardless of gender, race/ethnicity, or HAMS eligibility. HAMS screening can therefore be a productive learning experience that may reduce patient concerns about participating in HAMS. As such, fostering screening among PLHA of color can be an important component of reducing racial/ethnic disparities in HAMS. HIV/AIDS medical studies (HAMS) are research studies designed to evaluate promising therapies to combat HIV infection; treat and prevent opportunistic infections and cancers associated with HIV/AIDS; address the complications of antiretroviral therapy; reconstitute immune systems damaged by HIV/AIDS; and better understand the biomedical consequences of HIV infection . As suchIn the United States, HAMS are conducted by clinical trials research units (CTRUs), located in hospital centers and other medical settings. PLHA typically gain access to HAMS through a screening process used to determine eligibility. The screening process may be formal or informal and typically includes a health history interview, review of the characteristics of HAMS for which the participant may be eligible, medical testing if needed, review of consent forms, and coordination with the patient’s primary care provider. PLHA found eligible for HAMS during screening may then enroll into the trial or study. However, PLHA of color are substantially less likely to gain access to screening than their White peers , 12.The set of barriers that reduce access to HAMS for PLHA of color are complex and operate at multiple levels of influence , 9. At tscreening, a relatively low-risk and non-threatening activity, in contrast to the decision whether to enroll in HAMS, a potentially higher-risk activity. This strategy was a means of encouraging PLHA of color to explore HAMS and increase access to the CTRU setting. The ACT2 intervention was highly efficacious in increasing rates of screening for HAMS among PLHA of color, with approximately 50% of those in the intervention arm screened, compared to < 5% of controls [We recently conducted a randomized controlled trial to evaluate the efficacy of a peer-driven intervention to increase HAMS screening rates for PLHA of color, called the “ACT2” intervention ,10,20. Tcontrols .Screening is a crucial early step necessary to access HAMS, and also has potential to yield a number of other benefits whether or not an individual enrolls in a study. First, it communicates to CTRUs that PLHA of color are interested in HAMS and can therefore play a role in reducing racial/ethnic disparities in HAMS. For that reason, participating in screening may yield a sense of satisfaction from having engaged in an altruistic activity. Further, screening can improve a patient’s knowledge about HIV and HAMS, and also provides PLHA of color with access to the CTRU for the future when interest in HAMS and/or need for HAMS may be greater. Yet despite the importance of HAMS screening, little is known about participants’ screening experiences. However, such knowledge is vital and can be used to inform intervention efforts to tailor or improve the screening experience for under-represented groups.The overall goal of the present study is to describe the HAMS screening experience among PLHA of color, using both quantitative and qualitative data. We also explore potential gender and racial/ethnic differences in screening experiences, as well as potential differences based on HAMS eligibility. To explore factors underlying the decision to be screened for HAMS, as well as the experience of screening and the real-life context in which it occurs , we seleThe present study focuses on a subset of participants enrolled in the cluster randomized controlled trial to evaluate the ACT2 intervention . ParticiParticipants were assessed at three time points: baseline, and 4- and 12-months post-baseline, and received $25 for each. Interviews consisted of structured instruments, lasted approximately one hour, and were administered on laptop computers using both computer-assisted personal interviewing (CAPI) for the introductory sections and audio computer-assisted self-interviewing (ACASI) for the remainder of the interview at a project field site.In addition to structured interviews, a total of 35 in-depth qualitative interviews were conducted with a randomly selected subset of participants who were screened for HAMS from the intervention arm. For the present study, transcripts from these 35 interviews were placed into a random order. Starting with the first transcript, we examined whether the qualitative transcripts were generally similar to or different from the quantitative findings with respect to screening experiences. We examined transcripts until data “saturation” was reached, meaning that no new information or themes were observed in the data . We reacAt baseline demographic and background, characteristics such as gender, race/ethnicity, sexual orientation, and age were assessed with a structured measure . Health At each follow-up interview, experiences of screening (14 items) were assessed using a modified version of the Experiences of Screening subscale of the Harris Survey ,30. The A total of 198 individuals in the intervention arm initiated screening for HAMS. A total of 93.9% of these participants (N=186) provided data on their screening experiences. The most common reason for missing data on the Experiences of Screening scale was that participants did not report being screened in the interview, although they had presented for screening at the partner CTRU. This unexpected finding may also be due to the generic nature of the term “screening,” which is often confusing to people, because they are screened for so many conditions in a variety of settings . In otheDescriptive statistics (mean and standard deviation or percent) summarized demographic and health characteristics as well as the experiences of screening. The associations between race/ethnicity (African-American/Black vs. Latino/Hispanic), gender , eligibility (yes/no) and experiences of screening were examined using Fisher's exact test, with version 12 of Stata , since mIn As presented in Most (86.6%) participants reported they understood the screening process very well. Similarly, most (81.2%) stated they felt they understood what HAMS are usually trying to study, and what they would have to if they joined an HAMS (84.4%).Most (80.1%) stated that they were very willing to get screened for an HAMS again in the future. Almost all (98.4%) would recommend a close friend living with HIV/AIDS to get screened at the site where they got screened, and 96.2% would give the same recommendation to a family member.There were no race/ethnic, gender, or study eligibility differences in experiences of screening.The three case studies are presented below, selected to complement the quantitative findings. While each case study participant necessarily had largely positive comments about the screening experience, each also had his or her own unique perspective on motivations for screening and the screening experience, including aspects of the ACT2 intervention as well as other factors.Marc “very interesting and knowledgeable.” Marc pointed out that while he was indeed given information about HAMS during the intervention, “nothing was forced on (him),” neither information nor participation in HAMS. He described the ACT2 intervention approach as making the concept of HAMS feel “less threatening,” and this got him “more intrigued” about what participating in HAMS could mean for him. He also reported coming into the intervention with a range of misconceptions and fears about HAMS, stating, “(I had that) mentality …when you say ‘guinea pig.’ No, hell no, I’m not being nobody’s guinea pig, you know what I mean?” However, Marc found that the more he discussed HAMS in the group and in the peer education session he conducted, the more comfortable he felt with the concept of exploring biomedical studies. Even the language he learned in the group sessions had an effect on his thinking. Marc noted, “By me using the term, ‘clinical trial’ (as opposed to ‘experiments’), it’s kind a softening things up a little bit and it’s more interesting (to me).”Marc credited the ACT2 intervention with broadening his perspective on HAMS. Marc, in general, valued gaining knowledge about HIV infection and health in general, and felt that the ACT2 intervention was consistent with that value. He described the group sessions as, “What I don’t know can’t hurt me, but the more I know can help me, you know what I mean? So by me getting screened it actually, to me it just made me feel better like knowing more about what I’m gonna do, the disease I’m battling with, you know what I mean? Because you can never know too much, but you can always know to less, which is no good, you know.” He also noted that a desire to contribute to society by participating in biomedical research was another factor motivating his being screened for HAMS. Marc was not found eligible for a trial at the time of the screening, as is common in HAMS. Marc reported that he was not particularly disappointed about being found ineligible, saying he was not sure he was actually ready to participate in an HAMS at that point in time, but that he would consider enrolling in HAMS in the future.Regarding his reasons for deciding to be screened for HAMS, he reported: “I have a health care provider now (at the new clinic) and everything is good… And what was so cool about it is like when I was going to the clinical trial (screening), I’m like, the clinic is right here, and the clinical trials is right here, so you couldn’t give me no better, you know what I’m saying?... He’s (the doctor) got a beautiful clinic over there, I mean the staff is caring, they respect (me) and they are concerned.” He was pleased that the HAMS screening location was now in the same building as his new primary health care provider, which, for him, reduced one of many structural barriers to screening that PLHA of color experience, as described above. Indeed, Marc stated his intention to screen for HAMS on a regular basis.Yet screening yielded an unexpected benefit for Marc: During the screening visit, he learned that the hospital where the CTRU was located also housed a large and well-regarded HIV clinic. Marc had long been unsatisfied with his health care provider and decided to switch to this clinic, in large part because he felt comfortable with the HAMS screening experience and the CTRU setting generally, which he experienced as professional, competent, and caring. He described his experience with changing health care settings as follows, Susan “hectic,” because her grandson lived with her and she also took care of her granddaughter while her daughter was at work during the week. She described herself as very tired all the time and that her body felt older than it really was. Susan reported having a positive response to the intervention sessions. She noted, “(HIV is) my problem, but it’s a nationwide problem…and you know, every time a new medication comes out, this is how it comes out (through HAMS)… and (it’s important to) to realize that we are at a place where we are today because other people did (HAMS).” She continued to say that not having knowledge of HIV “makes the disease 10 times worse,” but at the same time, knowledge can be a burden. She herself struggled with how much information she wanted about HIV, but came to the conclusion that she would rather know everything there is to know.Susan has been HIV-positive for many years and suffered from many of the effects of HIV infection, including fatigue, memory loss, and neuropathy and also side effects from ART, such as diarrhea. She had also experienced a heart attack and a stroke in the past, leaving her quite frail. Further, Susan lived a life she described as “I stress over the medication. That’s the only fear I really have, you know, but the good part is, is that I’m gonna be part of trying to make it better for the next person because that is my goal because I know what I go through with this.” Susan reported that the staff at the CTRU was very helpful when she was screened. She felt welcomed there and that they took their time to explain the process to her and to answer all of her questions. She said, “I meet him (the screener), I’m like wow, okay. We talked in depth, went through my  history and he was just like so cool, and he get to the point and I had a couple of concerns.” Susan was found eligible for an observational study, and gave her first blood sample that same day.This desire for more knowledge about HIV influenced Susan’s decision to be screened, despite her doubts and fears about HAMS. On her feelings before the screening she said, Juanita “I didn’t wanna be anyone’s guinea pig. (But) I had misconceptions. I always thought  it was a pill and they gotta hook you up to all kinds of machines you know … A lotta times people think that you need to stop taking your medication in order to be in a trial and that’s not so, you know…. A lotta people think you have to give up your doctor. But you don’t.” Further, Juanita was impressed by coming to understand that, if she enrolled in an HAMS, she would have a choice about continuing to participate, and she could drop out of a study at any time. She noted, “It’s not like signing away your life (if you join an HAMS).”Juanita had been infected with HIV for over a decade at the time she joined the study. After initially learning she was infected with HIV, Juanita felt a desire to contribute to her community to help stop the spread of HIV to others. Juanita was struck by the fact that women commonly avoid HIV testing due to fears of stigma. She believed that education is the most important tool for HIV prevention, and it was this desire to learn more about HIV that motivated her to join the ACT2 Project. In the group sessions Juanita was struck by the large number of misconceptions about HAMS that are common in communities of color, and a high level of mistrust of HAMS, both of which she herself also shared. For example, she stated, “(ACT2) is (you) tell somebody and they tell somebody and the word gets around so then it’s more lax (relaxed), - you know, (after educating peers you are more) willing to be part of a study and be willing to be part of a trial.”One component of the ACT2 intervention entails participants being trained how to educate their peers about HAMS. Grounded in her concern for her community and for vulnerable women in particular, Juanita particularly appreciated these aspects of the program. She found that during the course of conducting peer education, her own past misconceptions about and other negative attitudes toward HAMS continued to diminish. She noted, “So you know it all has to do with the approach of the (person who conducted the screening), and he was very nice, he was you know, friendly and open. It seemed like I had known him for you know, a lifetime. Everybody (at the CTRU) is like, real open, real friendly, real nice, nonjudgmental, and that sort a thing attracts people.” Juanita was not found eligible for an HAMS at the time of screening, a fact that made her “a little sad” because she had a strong desire to contribute to research and to her community. However, she stated she planned to stay in touch with the CTRU to inquire about new studies as they open up, and the unit agreed to contact her when HAMS open up for which she might be eligible.Juanita was screened for HAMS during the project and described her experience as quite positive. She noted that one of the most important aspects of screening was how she was initially welcomed at the CTRU. She said, This is the first study to explore the experience of screening for HAMS among PLHA of color. Screening, whether done formally (as in the present study) or informally, is a crucial early step in the process of enrolling in HAMS. Yet PLHA of color are less likely to gain access to screening than their White peers. However, to date the experience of screening for HAMS has rarely been the focus of study, a gap the present study addresses.Overall, participants had a robustly positive experience during the screening encounter, for example, reporting they were treated with dignity and respect, were able to understand HAMS better after the screening encounter, and would be willing to screen again and recommend screening to others. Screening experiences were positive regardless of participant gender, race/ethnicity, and HAMS eligibility. The case studies presented suggest the screening encounter was more pleasant than expected for some, as PLHA of color commonly experience fears and misconceptions of the CTRU system.All participants in the present study engaged in the multicomponent social/behavioral ACT2 intervention prior to screening, which we surmise is a major contributing factor to the positive screening experience, as highlighted in the case studies. The ACT2 intervention provided participants with an opportunity to explore individual, organizational, social, and structural barriers that PLHA of color experience to HAMS, and articulate their fears and concerns about HAMS with peers prior to screening ,10,23,20Five of our questions measured in the quantitative data were answered with less than 85% satisfaction, suggesting ways of improving the screening experience. These areas touched on trust and comfort with the person who conducted the screening, understanding what HAMS are trying to study and what is required of participants, and willingness to get screened again. These areas warrant exploration in future research to further improve the screening experience.The study may be subject to self-selection bias  in that Study findings have important implications for reducing racial/ethnic disparities in HAMS. Providers often assume that PLHA of color are not interested in HAMS, and therefore do not refer them to CTRUs for screening ,33,34. H


Trials in October 2015 and take an opportunity to continue the much-needed debate about what applied scientific realism is. The paper by Jamal et al. is useful because it exposes the challenges of combining a realist evaluation approach (as developed by Pawson and Tilley) with the randomised controlled trial (RCT) design.In this paper, we respond to a paper by Jamal and colleagues published in We identified three fundamental differences that are related to paradigmatic differences in the treatment of causation between post-positivist and realist logic: (1) the construct of mechanism, (2) the relation between mediators and moderators on one hand and mechanisms and contexts on the other hand, and (3) the variable-oriented approach to analysis of causation versus the configurational approach.We show how Jamal et al. consider mechanisms as observable, external treatments and how their approach reduces complex causal processes to variables. We argue that their proposed RCT design cannot provide a truly realist understanding. Not only does the proposed realist RCT design not deal with the RCT’s inherent inability to “unpack” complex interventions, it also does not enable the identification of the dynamic interplay among the intervention, actors, context, mechanisms and outcomes, which is at the core of realist research. As a result, the proposed realist RCT design is not, as we understand it, genuinely realist in nature. In October 2015, Jamal and colleagues [We fully agree with the authors’ analysis of the shortcomings of RCTs of complex public health interventions. The RCT design has a number of limitations which make it not only difficult to apply to truly complex interventions but also incompatible with a realist approach to research, as we will describe herein. Although scholars like Blackwood et al.  have claBelow, we explain how we identified three differences between the position of Jamal and colleagues and our own understanding of scientific realism. These are related to paradigmatic differences in the treatment of causation between post-positivist and realist logic: (1) the construct of mechanism, (2) the relation between mediators and moderators on one hand and mechanisms and contexts on the other hand, and (3) the variable-oriented approach to analysis of causation versus the configurational approach.In essence, Jamal et al. propose “realist RCTs” that use a technical process  to test hypotheses about observable phenomena. However, realism acknowledges that not all that matters can be observed Table . In partThe notion of mechanism is central to understanding disease aetiology and treatment. Mechanisms are also central in realist thinking, but these are conceptualized differently: interventions trigger mechanisms in specific contexts, and that leads to outcome patterns. The nature of mechanisms has long been a topic of discussion in realist circles –10, but By their very nature, mechanisms are latent, invisible and sensitive to variations in context . MechaniJamal et al. define mechanisms as aspects of interventions. For instance, on p. 2, Jamal et al. write “The evaluator needs to hypothesise and test how the intervention theory of change interacts with context to enable (or disable) implementation, causal mechanisms and, ultimately, outcomes.” It is, however, not the “intervention theory of change” that interacts with context. Rather, scientific realism holds that interventions take place in specific contexts and address actors, who decide (or not) to change their behaviour, choices or decisions in response to the resources and opportunities offered by the intervention.Mechanisms are also characterised by Jamal et al. as external treatments. On page 2, the authors write that “Realist evaluators have viewed interventions as ‘working’ by introducing mechanisms that interact with features of their context to produce outcomes.” This wrongly implies that mechanisms can be introduced into a situation and are thus external; scientific realism holds that mechanisms are not external factors but latent powers and capabilities, which are a function of the interaction between intervention resources and responses of participants.All but one of the “mechanisms” presented by Jamal and colleagues in Table “In this stage, we will test hypotheses derived in stages 1 and 2 via quantitative analyses of effect mediation (to examine mechanisms) and moderation .” These authors also write that “Causal mediation analysis helps to identify process or mediating variables that lie in the causal pathways between the treatment and the outcome….Mediators are post-baseline measures of interim effects which may or may not account for intervention effects on end-outcomes” (p. 6).Related to the conceptualization of “mechanism” is the analytical approach to identifying mechanisms and attributing effects to these entities. In several instances, Jamal et al. propose to use mediation analysis techniques to identify what mechanisms are at play. For instance, they write on p. 6: This explanation demonstrates the authors’ analytical strategy. To clarify how their approach is in contrast with, if not opposition to, the scientific realist approach, we turn to Mahoney . This auMahoney identified a second definition of mechanism, which is “views causal mechanisms as mid-level theories or variables that can be used to explain a fairly wide range of outcomes” . Here, c“an unobserved entity that, when activated, generates an outcome of interest” [A third definition is used by scientific realism, which considers a causal mechanism as nterest”  (p. 581)nterest” . This geJamal et al. seem to have adopted the first definition that reduces mechanisms  to mere variables—although they are perhaps moving towards the second definition. In any case, their use of the terms “mediation” and “moderation” implies a variable-oriented approach to analysis in contrast to the configuration-oriented perspective that acknowledges complex causation adopted in scientific realism.relationship between context and mechanism. Hypotheses should present a set of programme theories that explain how the outcome patterns can be explained by a configuration of intervention, actors, context and mechanisms. This reflects the acknowledgement of complex causation in realist evaluation.Jamal et al. extend the variable-oriented approach to the formulation of the hypotheses. The authors present how they developed a set of so-called pre-hypothesised intervention mechanisms  separately from a set of pre-hypothesised contextual barriers and facilitators. We can only assume the authors followed this pathway because it would be easier to statistically test the various hypotheses as separate strands. However, developing configuration-mechanism-outcome configurations entails more than “segmenting” the programme theory into a series of variables about context and another on dealing with what they call “intervention mechanisms”. In scientific realism, the explanation relies on showing the This does not mean that realist research opposes the use of quantitative data. Realist research would rather not conceive of quantitative measures as “variables” (in the sense of things that vary in amount and cause subsequent variation in the next item in the equation) but as “indicators” . Using the latter definition, it is entirely possible to use quantitative measures for any of context (C), mechanism (M) or outcome (O), assuming of course that the C, M and O have been theorized previously, and that the indicators used are “fit for purpose” for that theory. This is a configurational usage of indicators as opposed to variable-based analysis.In summary, in scientific realism, the analysis does not depend on assessing statistically the correlation between variables representing intervention, effect, moderators and mediators. Rather, the analysis uses whatever data and analytic methods appropriate to build, support, refute or refine plausible explanations that incorporate intervention, actors, outcomes, context and mechanisms. This brings us to our third way in which we consider scientific realism to differ from the methodology proposed by Jamal and colleagues.The final difference in the paper of Jamal et al. relates to the capacity of the RCT to unpack and make sense of the dynamic interplay among the intervention, actors, context and mechanisms that, from a realist perspective, contributes to the outcome patterns within a complex intervention. If one considers that CMO configurations (as proposed by Pawson and Tilley) can be assessed in a RCT, then this design should be able to demonstrate how and why outcome patterns are caused by mechanisms “triggered” in specific contexts. Here again, mechanisms are to be understood from the realist perspective and not as a chain of factors between the intervention and the outcome. The design should also be able to demonstrate how and why such CMO configurations vary for different people or in different contexts and change over time. Given the need for randomisation and control in an RCT, only relatively few and simple CMO configurations can be tested at a time. At best, then, the RCT may help us in assessing the relative contribution of mechanisms to outcome patterns if the causal configuration is uniform but not when it is likely that different mechanisms will generate different outcomes in different circumstances, as is the rule rather than the exception in any health intervention.Jamal et al. write that “This paper provides the first guidance on the theoretical and methodological process of undertaking a realist RCT” (p. 7). We feel that this claim is somewhat premature. Not only has the primary study  that is The core question concerns how far an approach based on definition of mechanisms 1 and 2 of Mahoney  can be cThe paper by Jamal et al. is useful because it exposes the challenges of combining a realist evaluation approach (as developed by Pawson and Tilley) with the RCT design. However, the proposed approach does not allow testing theory in accordance to realist research principles. Not only does the proposed realist RCT design not deal with the RCT’s inherent inability to “unpack” complex interventions, it also does not enable the identification of the dynamic interplay between intervention, actors, context, mechanisms and outcomes that a configurational analysis demands. As a result, the proposed realist RCT design is not, as we understand it, genuinely realist in nature.informed RCTs would offer a way forward.We might be accused of blocking possible innovation, but the guidance presented by Jamal et al. risks causing methodological confusion for researchers trying to understand realist research as espoused by Pawson and Tilley. This proposal for a realist RCT is indeed symptomatic of the mainstreaming of realist research into the wider health research and policy domains. It raises questions about the extent to which the RCT methodology can be modified to accommodate scientific realism. We showed that Jamal et al. consider mechanisms as observable, external treatments, and how their approach reduces complex causal processes to variables. We argue that their purportedly realist RCT design cannot provide a truly realist understanding, as it lacks compatibility with the analytical orientation needed to theorize and conduct realist research. As a consequence, it does not allow for plausible causal claims, nor does it produce warrants for transferable knowledge. This notwithstanding, we believe theory-C, context; CMO, context-mechanism-outcome configuration; M, mechanism; O, outcome; RCT, randomised controlled trials; RE, realist evaluation


Biopolymers and biopolymer colloids can act as controlling agents and templates not only in many processes in nature, but also in a wide range of synthetic approaches. Inorganic materials can be either synthesized ex situ and later incorporated into a biopolymer structuring matrix or grown in situ in the presence of biopolymers. In this review, we focus mainly on the latter case and distinguish between the following possibilities: (i) biopolymers as controlling agents of nucleation and growth of inorganic materials; (ii) biopolymers as supports, either as molecular supports or as carrier particles acting as cores of core–shell structures; and (iii) so-called “soft templates”, which include on one hand stabilized droplets, micelles, and vesicles, and on the other hand continuous scaffolds generated by gelling biopolymers. During the natural synthesis of inorganic matter in living organisms, referred to as biomineralization, biogenic macromolecules are not only present in the crystallization medium, but play a crucial role in the mineral formation. Biomacromolecules,  can have thereby two main functions: (i) a controlling effect on nucleation and growth of the inorganic material, and (ii) a structuring function, either confining spaces or acting as supports or as scaffolds for the growth. As a result of the interaction of organic and inorganic matter, nature is able to create hybrid materials whose exquisite structures and properties continue to impress humankind . Egg sheIt is clear that all synthetic routes based on the use of (bio)polymers as controlling and templating agents in inorganic synthesis have in one or other way their origin or inspiration in natural strategies. We do not wish, however, to insist once more on the well-known ditty on the use of nature as “bioinspiration” for science. Our aim, probably more modest, is to classify and review here some of the recent – and in our opinion most representative – synthetic works involving the use of biopolymer and biopolymer colloids for the design of inorganic and inorganic/organic materials, with special emphasis on particles and particle synthesis., in situ/ex situ, ex situ/ex situ, and in situ/in situ. These different strategies for the formation of hybrid materials have been recently reviewed elsewhere in detail 47], Fe2O2O3 , and CdS2O3 –52. Pu e2O3  and semi2O3 –65.B2. Biopolymer particles as “supports”: In the area of preparation of hollow particles it is common to distinguish between “hard” and “soft” templates [emplates –59. Thisemplates  for a reLi et al.  preparedWhen referring to polymer particles, the denomination “hard template” may sound somehow odd, even more in the case of microgel particles, which are definitely not “hard”. However, in our classification we consider within this group all approaches in which a shell is formed on the surface of a particle. As an example, Boissière et al.  synthesiC1. Biopolymer-stabilized simple geometries : Surface-active polymers can assemble in solution and in heterophase systems to form defined geometries, most typically spherical, such as micelles, vesicles, or even stabilized droplets. As in the case of “hard templates” stated above, the approach has been very productive with synthetic polymers [polymers ,60, but + ions to metallic silver without addition of any additional reducing agent .Alginate is another of the gelling biopolymers used as a scaffold. An alginate-influenced growth of Co, Ni, and CoNi nanoparticles was reported by Coradin et al. . The samGold and AuNi alloy gelatin nanocomposites were developed by Brayner et al. . A gelat2 and subsequent calcination.A further example of a heterogeneous catalyst was reported by Taubert’s group with gold/cellulose nanocrystal hybrids produced in the presence of ionic liquids . Also foScaffold templating can also be achieved with starch and even with peptides. Thakore et al.  synthesiThe application of biopolymers  as controlling agents or as templates of inorganic precipitation and crystallization is not only present in nature , but is also a versatile strategy for the design of inorganic and inorganic/organic hybrid materials in the laboratory. On one hand, biopolymers may assemble forming structures that serve as confining spaces or scaffolds in which the formation of the inorganic component takes place. On the other hand, the presence of functional groups such as carboxylic, amino or phosphate groups can provide a high ability to bind metal ions or to interact with growing crystal faces, influencing nucleation and growth.Hydrogels, such as those formed with chitosan or gelatin, are very commonly used as polymer matrices for the synthesis of porous structures. Although in general the inorganic material is formed in situ , there are also some examples in which previously formed nanoparticles are combined with the biopolymer and incorporated into the matrix after gelation.In most cases, biopolymers have been either used in bulk solutions or applied to surfaces, so that the resulting material is a continuous hybrid structure. However, they can also be used to generate “discrete” structures either by using single molecular chains as supports  or by using particle systems. Hydrogel approaches can also be confined to the spaces of particles.Clearly, synthetic polymers are often a more economic and versatile alternative, but biopolymers can be especially interesting in those applications in which biocompatibility or biodegradability are an issue, such as biomedical applications. In addition, biopolymers may be also good model systems. In this sense, for instance, peptides or nucleic acids of defined length and structure can be very convenient models for studying polyelectrolyte systems. Furthermore, the high ability of biopolymers to form complex hierarchical structures is a major feature to be explored in the upcoming years. A better understanding of the interface between the biopolymeric component and the growing inorganic matter will continue to be the crucial issue in the design of novel and more sophisticated materials.


Avoiding food allergens when eating outside the home presents particular difficulties for food allergic (FA) and intolerant (FI) consumers and a lack of allergen information in restaurants and takeaways causes unnecessary restrictions. Across Europe, legislation effective from December 2014, aims to improve allergen information by requiring providers of non-prepacked foods to supply information related to allergen content within their foods.Using in-depth interviews with 60 FA/FI adults and 15 parents/carers of FA/FI children, we aimed to identify FA/FI consumers’ preferences for written and/or verbal allergen information when eating out or ordering takeaway food.A complex and dynamic set of preferences and practices for written and verbal allergen information was identified. Overwhelmingly, written information was favoured in the first instance, but credible personal/verbal communication was highly valued and essential to a good eating out experience. Adequate written information facilitated implicit trust in subsequent verbal information. Where written information was limited, FA/FIs depended on social cues to assess the reliability of verbal information resources, and defaulted to tried and tested allergen avoidance strategies when these were deemed unreliable.Understanding the subtle negotiations and difficulties encountered by FA/FIs when eating out can serve as a guide for legislators and food providers; by encouraging provision of clear written and verbal allergen information, and training of proactive, allergen-aware staff. This, in tandem with legal requirements for allergen information provision, paves the way for FA/FIs to feel more confident in eating out choices; and to experience improved eating out experiences. For individuals who experience food allergy (FA) and food intolerance (FI) avoidance of allergens is the key recommended strategy in preventing negative health outcomes. Accidental allergen ingestion is potentially life threatening for many FA individuals , 2, and In order to improve the provision of food allergen information for FA/FI consumers when eating out, Europe wide EU legislation was introduced in December 2014. This requires providers of non-prepacked foods to supply written and verbal information related to the content of one or more of 14 specified food allergens within their foods. Within the UK, the Food Standards Agency (FSA) has provided guidance on how allergen information might be provided . HoweverWe explored the allergen-related information delivery preferences of FA/FI populations when eating out or ordering takeaway foods. Results serve to inform legislators in their future recommendations for allergen information provision, and act as a guide of ‘good practice’ for food providers who are required to supply food allergen information for FA/FI consumers.Within Europe, FA affects up to 5% of adults and 8% of children , and theThe implications of having to exclude one or more foods from the diet can present wide-ranging and unique challenges for FA and FI populations. FA populations describe the need for constant vigilance, with no guarantee that their efforts will be effective in ensuring successful avoidance of the offending food. This has been termed ‘trying to control the uncontrollable’ (p. 284).EU legislation  introducWhilst the intention of the legislation is to provide FA/FI populations with clearer information regarding allergenic ingredients, little is known about how consumers prefer allergen information to be delivered when they eat out—through staff or through written sources of information—or what leads to trust or distrust in these sources. Findings from research into the labelling of pre-packed foods suggest that FA customers combine information seeking strategies by using allergen advice boxes in conjunction with ingredients lists and familiarity cues to minimise their risk of accidental allergen consumption . When ofWe aimed to understand the preferences and trust cues used by FA/FI individuals when eating out in order to inform the provision of allergen information resources and to outline the implications of this for legislators, food providers, and the wider community. Conducted in the 6 months immediately prior to implementation of EU FIC (1169/2011) legislation, our research is the first to assess the allergen information delivery preferences of both FA and FI populations when eating out; and in particular, their preferences for written and verbal information. This research constitutes phase 1 of the project and ongoing follow-up research will assess the impact of ongoing changes in allergen information provision on FA/FI’s eating out preferences and behaviours.Ethical approval was gained from the University of Bath, Department of Psychology Ethics Committee prior to participant recruitment . A specialist market research agency recruited 75 participants to complete in-depth interviews. Of the total population, 60 were adults reporting FA/FI, and 15 were parents/carers of children aged up to 17 years with FA/FI. Within the latter group, although the experience of parents/carers was the primary focus of the interview, their FA/FI children were sometimes present and contributed to it. In order to represent the views of consumers throughout the UK, participants were recruited from England, Wales, Scotland, and Northern Ireland. A breakdown of participant characteristics is shown in Prior to interview, participants completed a screening questionnaire characterising their or (for parents) their child’s reactions to one or more of the 14 specified allergens. Characteristics were based on nature of reaction, speed of onset, and how FA/FI was diagnosed. This information was used to classify participants as IgE-mediated FA; or non IgE-mediated FA/FI which was either medically or non-medically/self-diagnosed. Thirty-nine participants (52%) were classified as having IgE-mediated FA, and thirty-six (48%) were classified as non IgE-mediated FA/FI. Of the 14 allergens covered by the legislation, FA/FI to peanuts, tree nuts, milk, soya, mustard, lupin, fish, crustaceans, cereals containing gluten, sesame seeds, celery, and/or sulphur dioxide were reported. No participants reported FA/FI to lupin or molluscs.Following written informed consent, in-depth semi-structured interviews were carried out with participants in their own homes on the basis of an interview protocol detailing questions and possible prompts (a copy of this interview protocol can be provided on request from the corresponding author). Interviews were carried out by RP, JB, or DR, and each interview was audio-recorded with participants’ permission. Initial questions engaged participants with the topic of food and experiences relating to allergy/intolerance diagnoses, adaptation, and day-to-day coping strategies. The interview then focused on participants’ experiences and behaviours when eating out. Participants were encouraged to discuss strategies and environmental/social cues which influenced their decision-making processes; and to consider these preferences in relation to current and future information provision within the new legislation. Interviews lasted between 60–90 minutes.In order to communicate the diversity of views and perspectives surrounding participants’ eating out experiences, interview recordings were transcribed verbatim and explored in detail using framework analysis . FramewoIdentified themes are illustrated in results. In order to maintain anonymity, participant details are indicated in brackets as follows: A/P refers to Adult/Parent; participant number; country of residence—E = England, S = Scotland, W = Wales and NI = Northern Ireland; and food allergens associated with FA/FI responses. Italicised text reflects interviewer prompts.use’, the ‘adequacy’ of the information, and ‘preferences’ for information provision. Additional theme-based quotes are available in Participants described written food allergen information resources in terms of day to day ‘Where possible, participants preferred to rely on written information in preparation for, and during, their eating out experiences. For many, particularly in relation to unfamiliar venues, written information provided the first tangible point of contact on which to base their initial food choices. Preliminary enquiries were made using venue websites to explore food options ; and chePreparation for eating out:I’ll look usually online—I thank God for the internet—at what their menu is. As I said, before we went to (European restaurant), I’d decided…I’d looked it up online and looked at their menu and gone, right, and I know I had a penne pasta dish….so I knew that one was going to be fine. (A14 G2 S: Milk)If you’re going in a few days, you can Google what the recipe is sort of thing, a rough guide, and you think, mm, that’s okay, and then you just reiterate when you get there, right, I’m allergic to this. So, you know, it’s just basically Googling things… We look in the windows and we try and read, they’ll put a sample menu or whatever, or outside and you try and read what kind of things are in there and if you can see that there is something that you think would be okay then it’s worth a try. In the venue:…I’d look at the menu….. I’d sort of look at the list, oh, yeah, I like that one, and then I’d look underneath, which would tell me the ingredients, most times, with most of them, and then I’d order it. …it’s fine because it (the menu) normally gives me, 9 times out of 10, it will tell me what’s in the food. So, if I go to a restaurant and there’s a fish, it will tell me how…it will normally say “Cooked with a white wine sauce” or cooked with whatever. It’ll say how it’s served. (A23 G2 NI: Milk)Well pizza (chain outlet) ….have the thing on the menu that says if you want to make sure of anything else in the ingredients, take a picture of this QR code, and if you take a picture of the QR code, it takes you to (chain outlet’s) website and you can check yourself. When written information, on menus in particular, was considered to provide adequate information about ingredients and food preparation, participants reported a sense of autonomy and control when making choices. In part, this normalised the process of their food selections by allowing participants to choose their meals without recourse to additional resources. This in turn gave them greater freedom and a sense of relaxation when eating out.Participants had mixed experiences in relation to the adequacy of written information resources and provided examples of good and poor practice. It was generally perceived that venues which provided more detailed allergen information would be more accommodating and caring towards FA/FI consumers . For somI think it was in (chain restaurant)….they’ve just started doing a gluten-free burger….with a gluten-free bun, and they even said…we try our best to avoid cross-contamination… So, when they actually mention that, it’s kind of reassuring that, oh, they actually know what they’re doing. …if it’s clearly labelled and I don’t have to be the one getting someone to search through a file or go and ask a chef. It makes a massive difference. You just feel comfortable. (A56 G1 E: Egg)Very poor…I think they ought to provide more information. It’s like they brought out that thing with calories now. They put the calories next to the menu, the meal. It’s a good idea but they should do that for allergies as well. A lot of places don’t do that. British restaurants and those sorts of things, they just add wheat to absolutely everything, so it’s impossible…..Things like that really aggravate me, and you find, particularly in restaurants, like the list of ingredients, it’s just not adequate. Within the context of the new legislation and more generally, participants had clear, though varied ideas on how best to convey allergen information in a written /visual format. As a basic principle, the overwhelming majority of respondents believed that written information regarding food allergen content in meals should be readily available. Ideally, information provision requiring minimal effort on the part of the consumer, whilst avoiding the potential risk of reliance on staff as intermediaries in information provision, was desired . ExpectaIf you’re going to be providing information, provide the information—don’t make the customer go and ask for it…Human beings are human and they make mistakes… In a busy restaurant where people are talking to you, you know, you could be given the wrong information actually, so I would like that information provided in written form somehow….I wouldn’t want to have to ask for it. …they’ve got the “V” and the “N” on the menu, it would need to be a symbol-based thing, I think….. Because if you…had a particular allergy, you would just be scanning the menu for that particular symbol or letter or whatever it may be. I think that would be far more useful than having the huge long list of every ingredient. All it’s got to have is a GF next to it and I’m happy. Or even if it says ‘not GF’. It would be better…I think that would be really, really useful, and if it doesn’t do that then I feel like I’m a pain. …if they just had a nice wee clear “We supply gluten-free” or “Ask our staff”, you know, to provide a list…if you do have any form of intolerances, and we can leave any ingredients out or something. …the menu, that “Oh, we’ve got a gluten-free section,”…that is something that they can start doing more, because some people may be embarrassed to talk about it and, you know, not…ask the question. …they have the list on every single item in there—you know, dressings…sauces…all the allergy ingredients information, is listed on there. So…you know what you’re getting and you know exactly what’s in everything….and they update it as well…so that’s brilliant. I would prefer a simple description, but I have been in restaurants where…I’m not too sure what it means…They maybe list about six different ingredients and…I can recognise so many of them, and some of them, I’m not too sure about. Although many participants requested a more detailed menu, it was also recognised that the inclusion of such detail might pose practical problems for menu presentation and readability; particularly in the case of comprehensive ingredient lists within main menus. A minority of participants also raised concerns about their own ability to identify and recognise the relevant allergens listed . SimilarAs an inherently social experience, participants reported that the seeking of verbal information relating to food allergens within dishes varied based on their familiarity with the eating out venue. In regularly attended venues, where a successful track record of eating out had been established over time, participants valued the feelings of confidence and relaxation which resulted from their previous interactions with helpful and accommodating staff. In unfamiliar venues, where no such prior relationships had been established and written information was judged to be incomplete, participants used a number of cues to assess the reliability of the allergen information provided by staff. Primarily, participants based these assessments on staff knowledge and more subtle perceptions of staff interest, engagement and attitude with regard to their dietary needs. Where staff knowledge  and demeThe (Asian restaurant), as I said, they done gluten-free. They were able to offer an alternative to soy sauce and everything. So, she was able to say, ‘Well, you can’t have noodles but you can have rice noodles.’ So, she was actually more knowledgeable than me on coeliac, so that was good. (Sandwich chain) are usually quite good because I…went to one a couple of years ago now, and I said, “Oh can I have that, but I’m allergic to cucumbers so you’re going to have to completely…” you know, and she said, “Well, that’s cut in the same machine, so you can’t have that.” So, they kind of know…what’s cut what and what’s doing what. So, (Sandwich chain) are quite good for knowing what’s in the products and stuff. You get some people that are quite perky and cheery and…Also, asking specifically as well… So, I’d say, like I might accidently say “No milk” and they’d be like “Do you also not want cheese?” or “No prawns” and they’re like, “Are you okay with..?” you know, this other thing. So, you know, you get some people that are quite on the ball in that sense. …if a waiter is really keen on like listening and just writing all the ingredients, just to make sure she speaks or he speaks to the chef. So, yeah, just basically communication and the way they treat those things. (A9 G1 E)The trust is in the staff, to begin with. I mean, they’re your first contact, aren’t they? If they have knowledge of the food, then I’m quite confident. If they have no knowledge of the food, then I think I’m not coming here again. (A18 G3 E: Milk)Some do say, “What do you mean, dairy, what do you mean?” and I say cream, cheese, milk, anything like that, and…what makes me laugh, people think I’m going to be allergic to mayonnaise because it’s from the eggs, and…I said, “Actually, it’s not dairy, even though it’s from the hen, it’s not dairy, it’s not a cow… (A26 G2 E: Milk)There’s been times in the past when I know…I can read people, and I know that they’re thinking “Oh, for God’s sake, this is a fad!” sort of thing, you know, and it’s not good enough. (A18 G3 E: Milk)I’ve had them just shrug their shoulders and say “I don’t know.” “Well, does the chef know?” “I don’t think he will,” you know, sort of thing…and you’re thinking, you’re joking…! Participants identified other factors which inspired trust or served as barriers to their perceptions of staff members as reliable information resources. Younger staff members were viewed as inherently less reliable as information resources. This was largely due to an absence of life experience, and the potential for a lack of personal investment in their appointed roles. For some, this perceived lack of reliability did not necessarily lie with young frontline staff per se, but pointed instead to a potential systemic problem relating to eating out establishments as a whole. Better training was thought to hold the key to greater levels of trust and confidence in the information provided by staff.Whilst a minority of participants sought verbal information as a safety clarification in addition to written information resources, the majority reported a sense of reluctance and embarrassment when making enquiries of staff. Although asking questions of staff was seen as a necessity by many participants; for others the perceived embarrassment of asking staff for further information led to self-imposed limitations in food selections, or unnecessary risk taking.Written information of sufficient quality was used as a baseline resource which liberated FA/FIs to make their food selections independently and without recourse to other information seeking strategies. Beyond the written resource itself, FA/FIs inferred a wider message of ‘understanding’ on the part of venues that provided adequate written allergen information, and were reassured by notices encouraging customers to ask staff about the allergen content of foods. This implied awareness gave FA/FIs permission to ask questions of staff with the expectation of an informed response; and without fear of embarrassment. At its best, accurate and trustworthy food allergen information delivered verbally by staff also enhanced FA/FI’s eating out experience. Judgements regarding the potential for accidental exposure to food allergens were contingent on subtle social cues suggestive of staff knowledge; and were assessed by FA/FIs accordingly. Where doubts surrounding verbal allergen information occurred, FA/FIs retreated to their default position of reliance on written information resources, and in turn limited the potential variety of venues and food options available to them as a result. However, with adequate written allergen information, and the positive interactions of reliable allergen-aware staff; FA/FIs experienced an increase in trust and loyalty to eating out/takeaway venues concerned.Fundamental to FA/FI’s concerns surrounding allergen information provision when eating out, was the need for constant vigilance to ensure allergen avoidance, balanced against a wish to avoid ‘drawing attention’ . EU FIC Given that strict allergen avoidance is necessary for many FA/FIs , 18 and In recognising the insights gained through the in-depth analysis of FA/FIs information preferences when eating out, we also acknowledge the limitations of the study. Given that we were seeking to understand the perspectives of those with both FA and FI it was necessary to use self-report measures to assess FA/FI status. Although this was done through the careful application of strict symptom-based FA/FI criteria; the assignment of some participants presented a challenge. However accuracy of allocation was less critical within the remit of the current study which sought a broader perspective on FA/FI populations’ preferences for written and/or verbal food allergen information when eating out. Due to the qualitative nature of our research we were also unable to account for the impact of demographic factors such as sex, age and region of residence within the UK. These factors may have affected FA/FI’s preferences in terms of allergen information provision and willingness to communicate with staff.In light of EU legislation requiring that eating out providers supply consumers with information regarding the allergen content of their foods, this study is the first to gain in-depth insights into FA/FI consumers’ preferences for the provision of allergen information when eating out or ordering takeaway foods. Findings indicate that FA/FI consumers were often ambivalent or conflicted in their preferences for written and verbal allergen information provision. FA/FIs overwhelmingly favoured tangible, written information in the first instance; and adequate written information often led to an implicit trust in subsequent verbal information. Where written information was limited, FA/FIs depended on social cues to assess the reliability of verbal information resources, and defaulted to tried and tested allergen avoidance strategies when these were deemed unreliable. Understanding the subtle negotiations and difficulties encountered by FA/FIs when eating out can serve as a guide for legislators and food providers; by encouraging the provision of clear written and verbal allergen information, and the training of proactive, allergen aware staff. This, in tandem with legally enforceable requirements for food allergen information provision provided by the EU legislation, paves the way for FA/FIs to feel more confident in their eating out choices; and to experience a safer eating out experience.S1 File(DOCX)Click here for additional data file.


In this issue of journal, we have an observational study on left main PCI, a hot debate in interventional cardiology field . They re


Conflict and a new disease pattern are hampering efforts to eradicate guinea-worm disease in the last four endemic countries. Julius Cavendish reports. A terrible itchiness is the first symptom of guinea-worm disease or dracunculiasis. Next, explains Adama Guindo, a village chief in eastern Mali, an agonizing blister appears on an ankle or foot. “You don’t see the worm to begin with,” he says. When the creature’s head emerges several days later, the pain is unbearable. Nausea, vomiting, diarrhoea and dizziness follow.“You can’t work or sleep, and if you can walk at all – it’s with a crutch,” he says. Extracting the worm takes on average between 30 and 60 days, as it must be done manually, by making an incision and twisting the worm slowing out around a stick. Secondary infection from the wound can lead to tetanus, permanent disability or septicaemia, which can be fatal.“You can’t work or sleep, and if you can walk at all – it’s with a crutch.”Adama GuindoGuindo’s home village of Télé, at the foot of the Bandiagara escarpment, a sandstone massif close to the border with Burkina Faso, is one of thousands of communities in Mali that were once ravaged by guinea-worm disease. “We had guinea worm so badly here that women from other villages were frightened of marrying our men,” recalls Ata Lougue.Only 30 years ago, a large proportion of the population was stricken with this debilitating disease and the granaries were empty, says Professor Ogobara Doumbo, a parasitologist at the University of Mali, who grew up in the area.Today guinea-worm disease stands on the brink of eradication – the goal is to wipe it out globally by December 2015 – a year from now. Although the eradication goal was revised after an earlier goal to stop human transmission of the disease globally by 2009 was missed, few public health campaigns have made such rapid progress.In the mid-1980s, 3.5 million new cases were estimated to occur annually, but in 2013, as a result of the intensive efforts to halt transmission, only 148 cases were reported – a reduction of more than 99% since 1989 – and the disease has been confined to four countries: Chad, Ethiopia, Mali and South Sudan.This year, the pattern has been similar. From January to September, 101 cases have been reported, with 11 of those in Chad, two in Ethiopia, 19 in Mali and 69 in South Sudan.So far, the World Health Organization (WHO) has certified 197 countries, areas and territories, including 185 WHO Member States, as being free of the disease.Efforts to wipe out guinea-worm disease date back to the years after smallpox was declared the first disease to be eradicated in 1979.In May 1981, the Interagency Steering Committee for Cooperative Action for the International Drinking Water Supply and Sanitation Decade (1981–1990) proposed the eradication of guinea-worm disease as an indicator of success for the 10-year clean water campaign.In the same year, WHO's decision-making body, the World Health Assembly (WHA), adopted resolution WHA 34.25 reinforcing the idea that the International Drinking Water Supply and Sanitation Decade presented an opportunity to wipe out the disease. As a result, WHO and the United States Centers for Disease Control and Prevention developed a strategy and a set of technical guidelines for a global eradication campaign.To give it a final push in 2011, the WHA called on the countries where the disease was still endemic to step up efforts to stop transmission and strengthen nation-wide surveillance to achieve their goal.Although the disease is still endemic in Mali, some parts of the country have been transformed by the global eradication campaign. In Télé, children stood giggling shyly when asked about the disease that once ravaged their parents’ communities. “They are too young to know what guinea worm is,” says Lougue, explaining that it has been years since anyone in Télé contracted the disease. In those days, people blamed sorcerers for poisoning their wells – they knew that people got infected from drinking water, but did not know how, she says.A key part of efforts to eradicate the disease has been educating people in the communities affected on how the disease is transmitted. Guinea-worm disease is transmitted via contaminated water, which means that the disease strikes hardest at communities without well pumps, water filters or wells protected by walls: the most impoverished, in other words.The guinea-worm parasites generally emerge from their victims’ flesh at the same time each year – in Mali’s case during the summer harvest season. The disease traditionally strips communities of labourers at a time when they are most needed. Crops rot in fields. Granaries – buildings of spiritual as well as practical importance, with doors traditionally covered in carvings of sun lizards, crocodiles and ancestor figures – stand empty.Children with guinea-worm disease are absent from school, while mothers with the disease struggle to look after their children.Wherever guinea-worm disease strikes, malnutrition and increased poverty follow in its wake. It creates “major barriers to social and economic progress in dozens of countries”, the Carter Center’s Kelly Callahan told a Ted Talks audience last year. “Guinea-worm disease is not a symptom of poverty, but a cause of poverty … So eradicating guinea-worm contributes to ending poverty,” she said. In the 1970s, the devastation wrought by guinea-worm disease caught the eye of French parasitologist Philippe Ranque, who began mapping the incidence of guinea-worm disease in Mali. In 1976, Ranque founded the country’s first parasitology department, teaching a cadre of young doctors about the disease’s epidemiology and dispatching them to the field to collect data, and later joined WHO to head the dracunculiasis eradication programme in the 1990s.When the Carter Center started working on guinea-worm disease eradication in 1986, in partnership with WHO, the United Nations Children’s Fund and health ministries in the then 20 affected countries, these young doctors jumped at their chance.Guinea-worm disease, they hoped, would become the second human disease in history to be eradicated; and, unlike smallpox, they would do it without administering a single vaccine.Doumbo, who was one of them, recalls: “Epidemiologically we put everything together to show that it could be eradicated by just changing people’s behaviour.”The best and cheapest way to do this, he says, is by teaching people to filter their drinking water, to use larvicide to kill water fleas that carry guinea-worm larvae, and to prevent transmission – by keeping anyone who is infected from wading into the drinking water sources, where worms embedded in them can release tens of thousands of larvae into the water to infect new victims.“You don’t need drugs or a vaccine,” says Doumbo, “just a few simple tools and an effective outreach campaign.”“You don’t need drugs or a vaccine, just a few simple tools and an effective outreach campaign.”Ogobara DoumboNot only is guinea-worm disease relatively easy to control, in theory, but the benefits of eradication far outweigh the costs. According to a 1997 World Bank study, the economic rate of return on the investment in guinea-worm disease eradication will be about 29% per year once the disease is eradicated – a rate that is based on very conservative estimates of the average amount of time infected workers are unable to work.So removing guinea-worm disease translates into hundreds of thousands of communities better able to work their fields, send their children to school and escape the cycle of poverty and disease.But while the techniques for controlling the disease are simple, the last few cases are proving to be the hardest to detect and contain. In Chad, dogs were found to be infected with the same worms that affect humans between 2012 and 2014. So, if infected dogs enter water sources, they too can infect humans – a situation that requires additional containment measures.Efforts to wipe out the disease in South Sudan and northern Mali have been hampered by recent conflicts in these countries.In 2012, for example, Mali reported only seven cases in the whole country – a record low. But since the conflict in northern Mali that year, this rose to 11 in 2013 – 10 of which were in the northern areas affected by the conflict – and from January to September this year, the country’s 19 reported cases were in the northern regions of Gao and Timbuktu.“After the conflict in 2012, we couldn’t reach the northern regions,” says Dr Gabriel Guindo, the Malian health ministry official in charge of the national dracunculiasis eradication programme.“This meant that people were able to contaminate water supplies and infect others,” he says, adding that since the French military intervention, government health workers have been slowly returning to Mali’s northern regions to do the necessary prevention work.“If we have access to all the regions without any problem,” Guindo reckons, then “by 2016 the problem should be solved.”