More than 90% of children living with HIV have been infected through mother to child transmission. The aims of our present study were to: (1) assess the utilization of the prevention of mother to child transmission (PMTCT) services in five reproductive and child health clinics in Moshi, northern Tanzania, after the implementation of routine counselling and testing; (2) explore the level of knowledge the postnatal mothers had about PMTCT; and (3) assess the quality of the counselling given.This study was conducted in 2007 and 2008 in rural and urban areas of Moshi in the Kilimanjaro region of Tanzania. Mixed methods were used. We interviewed 446 mothers when they brought their four-week-old infants to five reproductive and child health clinics for immunization. On average, the urban clinics included in the study had implemented the programme two years earlier than the rural clinics. We also conducted 13 in-depth interviews with mothers and nurses, four focus group discussions with mothers, and four observations of mothers receiving counselling.Nearly all mothers (98%) were offered HIV testing, and all who were offered accepted. However, the counselling was hasty with little time for clarifications. Mothers attending urban antenatal clinics tended to be more knowledgeable about PMTCT than the rural attendees. Compared with previous studies in the area, our study found that PMTCT knowledge had increased and the counsellors had greater confidence in their counselling.Routine counselling and testing for HIV at the antenatal clinics was greatly accepted and included practically every mother in this time period. However, the counselling was suboptimal due to time and resource constraints. We interpret the higher level of PMTCT knowledge among the urban as opposed to the rural attendees as a result of differences in the start up of the PMTCT programme and, thus, programme maturation. After comparison with earlier studies conducted in this setting, we conclude that when the programme has had time to get established, both its acceptance and the understanding of the topics dealt with during the counselling increases. More than 90% of the children living with HIV are infected through mother to child transmission (MTCT): during pregnancy, around the time of birth, and through breastfeeding ,2. WithoAlthough there has been an increased coverage of the prevention of mother to child transmission (PMTCT) programme globally , there aIn Tanzania, the estimated HIV prevalence of pregnant women attending antenatal care in 2007 was 8.2% . The PMTBefore and during the pilot testing phase of PMTCT in Tanzania, four studies were conducted in the Moshi district of the Kilimanjaro region. These studies were conducted at antenatal clinics and explored the mothers' knowledge about PMTCT, their infant feeding intentions, their willingness to test for HIV, and the counsellors' perspectives on the PMTCT programme -26. We sThe aims of this study were: (1) to assess the utilization of the PMTCT services, in particular HIV counselling and testing, in five reproductive and child health clinics in Moshi after the implementation of routine counselling and testing; (2) to explore the level of knowledge the postnatal mothers had about PMTCT; and (3) to assess the quality of the counselling given.Mixed methods were used due to the combined exploratory and descriptive research aims Table . We wereThis study was conducted from October 2007 to February 2008 at five governmental clinics in urban and adjacent rural areas of the Moshi district in the Kilimanjaro region in north-eastern Tanzania. HIV testing and counselling were offered on a routine basis in the antenatal care in all of the participating clinics; one of the urban clinics was part of the pilot project of the PMTCT programme in 2000; the other two urban clinics started with PMTCT in 2004, and the two rural clinics implemented the programme in June 2006.Compared with national data, the Kilimanjaro region has a higher antenatal participation (99% vs. 94%), higher rates of women giving birth in a health facility (70% vs. 47%), a higher level of education (64.9% of the women had completed primary school vs. 50.2%), and a higher literacy rate (91.6% of the women vs. 67%) . In addiThe sites for the data collection were the same five reproductive and child health clinics that were part of the studies eight years earlier -26. DuriThe questionnaire was translated from English to Swahili by an experienced Swahili teacher, fluent in English, and translated back to confirm wording and meaning. Thereafter, the questionnaire was pre-tested at the five clinics in the study and revised accordingly. Four research assistants, three of them students and the forth a retired nurse who also served as the main research assistant, conducted the interviews. Prior to the start of the study, they were familiarized with the questionnaire and trained in interview techniques by the principal investigator.The questionnaire consisted of the following: (1) socio-demographic characteristics; (2) information on clinical attendance, birth and infant feeding; (3) PMTCT practice at the clinic (counselling and testing for HIV); and (4) knowledge about PMTCT. Information about HIV status was not collected.http://www.epidata.dk and analyzed using SPSS PASW. We used descriptive statistics to assess categorical baseline characteristics. Pearson χ2 was used to address potential differences between the urban and rural clinics in terms of population characteristics, PMTCT practice and knowledge. The dependent variable in the crude and adjusted logistic regression analysis was knowledge about PMTCT. The adjusted logistic regression analysis included all the same variables as in the crude analysis. We used the SPSS "backward conditional" command: removal was set at 0.2; and 95% confidence intervals were given.Data was double entered into EpiData 3.1 software All but one of the 17 questions about PMTCT knowledge included in our questionnaire were drawn from an already tested questionnaire . Only miSocio-economic status was assessed by constructing an index using principal component analysis (PCA), commonly used when creating socio-economic indices in low-income settings . PCA is Among the included mothers, approximately one-quarter had antenatal attendance at a clinic other than one of the recruitment clinics where they came for immunization Figure . Since wWe conducted eight in-depth interviews with mothers: three with mothers coming to one of the recruitment clinics for DPT-HB and polio immunization, and five with mothers with a child less than one year old. The aim of the in-depth interviews was to elaborate on questions asked in the survey so as to gain a deeper insight and get answers not easily obtained from surveys.In addition, we carried out four focus group discussions (FGDs) with mothers. By employing FGDs, we aimed to make use of group interactions, which may help people to explore and clarify their views in a way that would be less accessible than in one-to-one interviews . One of The mothers coming for immunization were approached at the clinic by the main research assistant and the principal investigator and asked if they were willing to participate. The mothers included in the in-depth interviews and the FGDs were recruited in different communities in urban and rural settings of Moshi, assisted by the main research assistant's acquaintances and village leaders. The recruitment criterion was having a child less than one year. Thus, the mothers were purposively chosen on the basis of having been exposed to PMTCT activities within reasonable time.We also carried out five in-depth interviews with nurse counsellors, one in each of the recruitment clinics. They were approached by the principal investigator and asked if they were willing to participate. Finally, we observed a total of four PMTCT pre- and post-test counselling sessions at three of the recruitment clinics. In one of the urban clinics, we were not permitted to observe the counselling sessions, while in one of the rural clinics, we did not succeed in doing so. The observations were made after having received consent from the nurse counsellor and the mother being counselled. Individual informed consent was obtained from all of the participants in the in-depth interviews and the FGDs.A semi-structured interview guide was prepared specifically for each group of informants. Themes included were experiences of the PMTCT programme, mothers' knowledge about PMTCT, and perceived barriers to PMTCT. The mothers who came for DPT-HB and polio immunization and the nurse counsellors were interviewed at the clinics, whereas the mothers with a child less than one year old were interviewed in their private homes. The FGDs were conducted outdoors, in a private home or in a church.All of the in-depth interviews were carried out by the principal investigator (EFF). The interviews with the nurse counsellors were performed in English, while the interviews with the mothers were performed using the main research assistant as an interpreter. She was fluent in English and Swahili, as well as the main local languages. The FGDs were moderated by a nurse working at a local HIV organization. She had training and experience in conducting FGDs. The discussions were all conducted in Swahili. The FGDs and the in-depth interviews ranged in length from 45 to 90 minutes. The in-depth interviews, the FGDs and the observations at the clinics were all tape recorded and subsequently transcribed verbatim. Interviews conducted in Swahili were then translated into English.Qualitative data analysis was primarily performed by the principal investigator using a thematic content approach . The infThe study obtained research clearance from National Institute for Medical Research Tanzania, the Tanzanian Commission for Science and Technology, the Kilimanjaro Christian Medical College Ethical Research Committee, and the Regional Committees for Medical and Health Research Ethics for Region West, Norway.The median age of the 426 mothers was 25 years, and the median age of the infants was four weeks. Nearly half of the respondents reported that they lived in rural areas Table . The majThe sub-group analysis included 311 (72.9%) mothers, of whom 233 (74.9%) had attended antenatal care at one of the three urban clinics included in the study and 78 (25.1%) had attended one of the two rural clinics. We found significant differences (p < 0.001) between the mothers in the following areas: mothers who went to an urban clinic were more often Muslim, less often Chagga and usually wealthier than those who went to a rural clinic.All the 426 mothers had attended the antenatal clinic during their most recent pregnancy. The median number of visits was four (range 1-10). Relatively few mothers (17.8%) reported visiting the antenatal clinic during their first trimesters; the majority (69.0%) presented themselves during their second trimesters. The vast majority of the mothers (85.7%) had given birth at a hospital, a small minority (13.1%) at a health post, and only 1.2% at home or during transport.In the sub-group analysis, we found that the rural antenatal attendees were more likely to present themselves at the antenatal clinic as late as in the third trimester (29.5%) than the urban attendees (8.2%) (p < 0.001).The majority of the 426 mothers were familiar with the PMTCT programme at the antenatal clinics  difference between the urban and rural antenatal attendees with regards to PMTCT practices, i.e., receiving counselling and testing Table .The qualitative data generally confirmed the quantitative findings. The mothers had a favourable view of the PMTCT programme at the clinics and were informed about its content. They seemed to be aware that testing for HIV was part of the antenatal service before arriving at the clinics, and the majority stated that they had discussed it with their partners before attending. Testing was perceived as purely beneficial, both in terms of knowing their own health status and being able to protect their children from infection. No objections to testing were raised by the mothers who were interviewed. The nurse counsellors focused on each mother's opportunity to reject testing, but had never experienced a mother refusing to be tested for HIV. According to the nurses, the mothers were prepared to test when they arrived at the antenatal clinics. Further, the nurse counsellors explained the high acceptability with the fact that the mothers were aware of the benefits that an HIV-infected mother would receive:The mothers agree to be tested because they know that after they have been tested and found to be HIV-infected, they will get drugs to prevent the infection from mother to the foetus. Most clinics had group information about PMTCT for the antenatal mothers, followed by individual pre- and post-test counselling. Although the nurse counsellors seemed knowledgeable in PMTCT, several of the mothers stated that they had received insufficient information during the counselling. During the observations of the PMTCT counselling, we noticed that two of the nurse counsellors gave cursory counselling. In the other two observations, the mothers were given comprehensive information, covering the main areas of PMTCT, except for infant feeding. Due to time constraints, the information was given hastily and the mothers had little opportunity to interrupt with questions if they did not understand. The nurse counsellors were well aware of this potential quality constraint:We have a lot of clients and few nurses, so the counselling will sometimes not be quite good. During the interviews with the nurse counsellors and the observations of the PMTCT counsellings, we did not find any differences between the urban and rural antenatal clinics in the quality of the counselling being provided.The 426 mothers were well informed of the risk of MTCT of HIV through breastfeeding (99.8%) and during labour (97.2%), but only 61.5% knew that it could be transmitted during pregnancy (Table There were significant differences (p < 0.05) between the mothers attending antenatal care at the rural and the urban clinics: the urban attendees were more knowledgeable in nearly all subjects. Overall, the median number of correct answers was 12 out of 17. The urban attendees had a median score of 14 and the rural attendees had a median score of 5.5. The knowledge index had a Cronbach's alpha of 0.598. The median number of correct answers to the eight questions included in the knowledge index was six for the urban attendees and four for the rural attendees  theAs in the quantitative findings, the mothers in the in-depth interviews and the FGDs generally knew about the main transmission routes, but tended to overestimate the risk of transmission, especially through breastfeeding. There was a common misconception among the mothers that the infant was protected in the uterus, and thus could not be infected:The baby has security in the uterus. Overall, the mothers in the qualitative interviews tended to be knowledgeable about the use of condoms as a preventive measure during both pregnancy and the breastfeeding period. However, several expressed doubts as to whether their partner would accept using condoms, as illustrated in one of the observed PMTCT counselling sessions:You should also encourage your partner to test for HIV. If you tell him to use condoms during your window period until he has also taken the test, will he agree? No ... [laughter] he would say I am disrespecting him. (Mother being counselled)We did not find a difference in the level of knowledge about PMTCT between the urban and the rural mothers in the qualitative interviews.During the observed PMTCT counselling sessions, none of the nurse counsellors talked about infant feeding. Infant feeding counselling appeared to be a priority only for mothers who were HIV infected. The infant feeding options that the nurse counsellors stated that they gave to HIV-infected mothers were in accordance with the 2001 guidelines from WHO , namely:However, according to their experience, the majority of the mothers opted for EBF due to their financial situation. In general, the nurse counsellors believed that to exclusively breastfeed for three to four months was more feasible than the recommended six months, and several recommended this duration in the counselling:Most HIV-infected mothers choose to exclusively breastfeed up to three months, because feeding formula from birth will be too expensive. Even at three months not all can afford to buy milk. In the quantitative survey, the mothers were asked the hypothetical question: how would they have fed their infants if they were HIV infected? Half of the mothers (49.5%) stated that they would have given cow's milk, 27.2% would have given formula milk, and 21.8% would have practiced EBF. There was a significant difference (p < 0.001) between the mothers attending the rural and the urban antenatal clinics: the rural attendees were more inclined to give cow's milk (74.4%) and the urban attendees more inclined to give formula milk (32.2%) and to practice EBF (26.6%). The mother's choice of infant feeding if she had been HIV infected was strongly associated with her PMTCT knowledge (p < 0.001). Mothers who would have opted for cow's milk were more likely (60.8%) to have little knowledge about PMTCT, and mothers who would have chosen EBF were less likely (10.8%) to have little knowledge about PMTCT.The majority of the mothers in the in-depth interviews and the FGDs seemed confused about how HIV-infected mothers should feed their infants. Many questioned the safety of breastfeeding and stated that they would not have breastfed due to the risk of infecting the child:I will ask a neighbour for cow's milk and boil it rather than use my own milk to avoid the risk of infection. I heard that if you are HIV infected and you breastfeed your baby, your baby will be infected as well, so how can you breastfeed? At the same time, several mothers showed notable knowledge about the protective advantages of EBF and how to reduce the risk of transmission through breast milk:I would breastfeed the baby for six months without giving anything. The first breast milk is very important to the baby. If you stop, you can never give breast milk again, because if you give alternatives, it will make bruises in the colon which will lead to transmission if it is mixed with breast milk. Make sure she (the HIV-infected mother) has no wounds on her breasts and the baby should not have ulcers in his mouth. In this study in the Kilimanjaro region in Tanzania of urban and rural mothers who had recently been through the PMTCT programme with routine counselling and testing coming for postnatal follow up, we noticed the following: (1) routine counselling and testing was greatly accepted, and nearly all of the mothers had tested for HIV; (2) overall, the mothers were knowledgeable about PMTCT; (3) there were large differences in the PMTCT knowledge of the rural and urban antenatal clinic attendees; (4) the nurse counsellors were generally knowledgeable about PMTCT and had confidence in their own counselling; and (5) the counselling was usually hasty with little time for clarification.Compared with the previous studies conducted eight years earlier -26, we fIn our study, we found 100% acceptance of HIV testing among the antenatal mothers. In the report from the pilot of the PMTCT programme in Tanzania , the volIt has been suggested that routine counselling and testing increase the acceptance of testing due to a view of it being a part of the "standard of care" offered to all antenatal attendees , thus reIt is difficult to compare the level of knowledge in our study with the level found in other studies because different questions were used. We may have documented a higher overall level of PMTCT knowledge than that found in many previous studies ,11,13-16We did not find any link between levels of education of the mothers and knowledge of PMTCT, which may be due to the generally high and equal level of education in this region. Nor did we find different levels of knowledge among mothers who reported having received HIV information and those who had not, which is probably because nearly all of them had received this information.In both the quantitative and the qualitative data, we found three main areas where the mothers seemed to have insufficient knowledge about PMTCT: (1) the possibility of MTCT during pregnancy; (2) the protective effect of condom use during pregnancy and the breastfeeding period; and (3) the infant feeding method that is recommended for an HIV-infected mother.We are unable to explain why so many mothers seemed to be unaware of the risk of transmission during pregnancy. In the previous study eight years ago , a much The mothers' apparent lack of knowledge about the importance of condom use during pregnancy and the breastfeeding period may be due to their misinterpretation of the questions Table . The queThere were major differences in the PMTCT knowledge of the mothers attending the urban and rural antenatal clinics. Among the factors that were associated with having little knowledge about PMTCT in the adjusted regression analysis Table  was thatIn the adjusted analysis, being non-Christian was associated with having less knowledge. However, non-Christians were barely represented in the rural group and thus cannot explain the difference in knowledge between the groups. Further, given that we found that the rural and urban antenatal attendees received similar PMTCT services Table , this doThere are many other factors, which are outside the scope of this study, which also could have explained the differences observed, like exposure to other HIV-related education programmes. What we know is that the PMTCT programme was implemented on average two years earlier in the urban clinics than in the rural ones. This may suggest that the differences observed in the PMTCT knowledge of rural and urban mothers could be due to the difference in the maturation of the PMTCT programme: the knowledge had had more time to get established in the population.However, the observed knowledge gap in the quantitative data between the urban and rural mothers was not found in the qualitative data. There could be several explanations for this. One is that the quantitative data might capture a trend not seen at the individual level. Further, the divergence between the methodologies and the way knowledge was measured may have influenced the difference in results. The qualitative instrument allowed a deeper understanding of the mothers' actual knowledge than the quantitative, more rapid assessments. This illustrates the usefulness of mixing methods that force us to present diverging results.The counselling that the nurse counsellors said they gave to HIV-infected mothers had not been updated to the 2006 WHO infant feeding guidelines , which gMost nurse counsellors seemed to perceive the risk of HIV transmission through breastfeeding as a greater threat than the risk of malnutrition and diarrhoea if the infant was not breastfed. Nevertheless, the majority of the nurse counsellors considered EBF the best option for most HIV-infected mothers because of their financial situations. Previous studies in the Kilimanjaro region indicated that the nurse counsellors did not have confidence in their own professional knowledge about infant feeding practices for HIV-infected mothers ,37 and tThe minority of mothers, who said they would have opted for EBF if, hypothetically, they were HIV-infected, were less likely to have little knowledge about PMTCT. The mothers' infant feeding choices may reflect their overestimation of the likelihood of HIV transmission through breast milk, or a lack of understanding of the advantages of practising EBF. The complexity of the issue and inconsistent infant feeding information may explain the large discrepancies in the level of knowledge about EBF among the mothers. Our findings further underscore the importance of a rapid implementation of WHO's 2010 infant feeding guidelines , with inIt seemed that the nurse counsellors prioritized giving infant feeding counselling only to the HIV-infected mothers. Due to time constraints, this seems to be a sensible approach. However, it is important that healthy infant feeding practices for both infected and non-infected mothers, with a particular focus on EBF, is covered at the antenatal clinics.Good counselling takes time, and a shortage of staff is a major barrier affecting mothers' PMTCT knowledge. The implementation of PMTCT at the antenatal clinics has increased the staff workload ,41. The We recommend that the nurse counsellors continue to give the majority of the pre-test information in groups to save time, as recommended in the national PMTCT guidelines ,22. In sIn Tanzania, it is the nurses, already overloaded with tasks, who are trained as counsellors. Experiences from other countries in sub-Saharan Africa have shown that the use of community or peer counsellors to augment counselling capacity is feasible and acceptable -45. FurtA possible bias in this study was linked to the recruitment procedure. The nurses working in the selected clinics recruited the participants in the quantitative study. This may have made it difficult for the mother to decline taking part in the study, which may explain the extremely high participation rate (99.1%). Furthermore, it may have introduced a social desirability bias, where the mothers answered with what they assumed would be the right thing to say, rather than what they actually thought.Additionally, recruitment from the clinics may have selected only mothers who had health-seeking behaviours. Due to the high regional immunization coverage , we do nThe questions we asked about knowledge were all closed ended. It is important to differentiate between knowledge by recall, which implies active knowledge, and recognition of correct answers given to closed-ended options, which implies passive knowledge. Thus, the relatively high level of knowledge in our findings may be falsely high. However, we used open-ended questions in the qualitative interviews, and these findings largely supported the quantitative findings. Furthermore, the questions in the survey about condoms use as a preventive measure during pregnancy and birth may have been too simplified an approach to address a more complex issue.The fact that the principal investigator, who also performed the fieldwork, was not conversant in the local language was a limitation to the qualitative data collection. The use of an interpreter may have created a distance between the interviewer and the interviewee and thereby moderated the quality of the interviews. Further, the principal investigator was unable to take active part in and moderate the FGDs. Efforts were made to decrease this limitation: the moderator was thoroughly informed about the topics of interest, and each FGD was transcribed and translated before the next FGD were performed so that subsequent adjustment could be made if necessary. The principal investigator analyzed qualitative data from transcripts that had been translated into English. To some extent, the translation process may have diluted some of the richness of the data.Furthermore, observations of PMTCT counselling sessions were not performed at two of the participating clinics, which make us unable to fully compare the counselling received at the different clinics. Last, the concurrent mixed-method design did not allow for information gained by one method to inform the next method as it would have if a sequential design had been conducted.Routine counselling and testing for HIV at antenatal clinics was highly acceptable in this region. However, the counselling was suboptimal due to time and resource constraints. We interpret a higher level of PMTCT knowledge among the urban as opposed to the rural attendees as a result of differences in the start-up times of the PMTCT programme and hence programme maturation. Furthermore, as this study is the second conducted in this setting, we deduce that when the programme has had time to get firmly established, both its acceptance and the understanding of the topics dealt with during the counselling will increase.The authors declare that they have no competing interests.All authors participated in the design and planning of the study. The field work was conducted by EFF, supported by RM. The analysis and write up was carried out mainly by EFF, IMSE, MMdP and TT. All of the authors read and approved the final manuscript.EFF is a medical doctor and PhD candidate. She has research experience from a qualitative infant feeding study in Zambia. TT has a Masters in African Linguistics and is a paediatrician and professor at the Centre for International Health at University of Bergen, with extensive experience in health-related research in sub-Saharan Africa. MMdP is a nutritionist with a PhD in public health nutrition. She has extensive experience in mixed-methods research in Tanzania, South Africa and India. Findings from this current study were compared with her previous studies in the Kilimanjaro region. RM is a medical doctor with a PhD. She is working at the community health department in a hospital in Moshi, Kilimanjaro, region and has experience in conducting research in the region. IMSE is a medical doctor with a PhD in child health and nutrition and has experience in mixed-methods research in Uganda.


The Gambia. People conducting a population-based survey randomly selected the hamlet of Tunku. The survey team waded across flooded paddy fields, constantly asking for directions. Tunku turned out to be a cluster of five mud huts perched on a hill on the bank of the River Gambia. The team found two families and one blind old woman there. The villagers could only reach their homes from the river using dugout canoes, and they grew their crops in fields that flooded. Why would anyone choose to live here, in this ‘end of the road’ place?Nigeria. Ibadan is an ancient city that grew around its traditional palace. Out of the city's overcrowded and labyrinthine streets, weeping mothers streamed daily to the tertiary teaching hospital less than half an hour away with children dying or dead from diseases such as malaria, diarrhoea, or marasmus. In the hospital, they saw clean wards with crisp white bed sheets — an unimaginable and unattainable luxury for them in their homes. Meanwhile, medical students ventured in the opposite direction, through the same labyrinthine depths and into homes in which gutters with filthy waste water ran through the middle of rooms and the latrine was just outside the window. Their purpose? A paediatric posting, but the challenges they found in these urban slums demanded a public health approach. Their traditional doctor's training was powerless in the face of such challenges.Those at the ‘end of the road’ in inaccessible areasMigrant communitiesThose in slums: pockets of poverty in urban areasPost-disaster communitiesCommunities in areas of conflict or in refugee campsCommunities affected by environmental degradation from mining, climate change or bad development projects.‘NTDs affect people who are neglected in every facet of development’Nairobi, Kenya. Known as a cantankerous old woman, she lived alone in a large house in the expensive part of town. The house and garden had seen better days. Someone came in to drop her daily meal and rushed out because of the strong smell of decay and the madness of the old woman. When she was found unable to walk because of a fall in her kitchen and forced to go to the clinic, it was discovered that she had blinding cataracts; her poor vision at least one of the causes of her apparent self-neglect. She epitomised neglect by self and by others – even in the absence of poverty.Like the people in Tunku and in the slums around Ibadan, poor and/or remote communities around the world – whether rural or urban-are often neglected, whether in Africa, the Amazon, Australia or the Indian sub-continent. However, neglected people can even be found in affluent communities.If we want to address neglected tropical diseases (NTDs), we have to focus on the communities affected. As David Molineux writes on pages 21-24, NTDs affect people who are neglected in a variety of ways: through poverty and lack of access to basic water and sanitation, health services, and education … In fact, just about every facet of development.How can eye care programmes respond to the challenge of reaching these neglected people? Here are some examples of different strategies.Midwives, who function as family health workers, form the backbone of health service delivery in Sri Lanka. In 2000, there were over 5,000 midwives in the country, each responsible for between 3,000 and 4,000 people. This network should – in theory- reach the entire population of Sri Lanka. In rural Sri Lanka, it was noted at a Sightsavers review of primary eye care in 2010, that the midwives are welcomed into people's homes and know every household and family member intimately: the child whose Road to Health chart is kept by his literate mother (Sri Lanka has a 98% literacy rate), the grandfather with hypertension, and the grandmother reluctant to wear her glasses. One even helped a father who was determined to harvest rainwater, diga well, and build a latrine. By being so close to their local community, these health service workers are able to provide the right support, to the right person, at the right time.Onchocerciasis occurs among rural communities who live beside the fast-flowing rivers in which the black fly breeds. This fly is the ‘vector’ for transmission of onchocerciasis: the pathogen which causes the disease enters the bloodstream of people when they are bitten by the black fly.Despite a major, decades-long programme of aerial spraying of the breeding sites, supplemented by treatment with the drug ivermectin, prevalence was still found to be high in some remote communities such as those in the highlands of Togo. A Special Intervention Zone was set up in Togo and in other countries with pockets of high prevalence in West Africa, and control measures were increased to ensure that people living in these remote areas were being protected.Since its launch in 1995, the African Programme for Onchocerciasis Control (APOC) has developed community-directed strategies designed to ensure that even the most neglected communities could be reached. APOC defined the critical factors as being:commitment by everyone involved, from national to community levelhealth system thinking: strengthening the health systems where they interact with the communities – on the ‘frontline’ of health care deliverypaying attention to broader issues: gender and equity, health workers’ roles, and community development and awarenessencouraging the community in its role to recruit and support the workersengaging and empowering the communities in the partnership.Adoptionof these strategies by governments has led to successful control of onchocerciasis in Africa, so that in many areas there is the real possibility of elimination of the disease. In addition, these strategies have formed the basis for control of other neglected tropical diseases, like trachoma, and have been adapted to address other health and development programmes meeting the needs of some of the poorest and most neglected people.In the 1950s, the leader of Ghana, Kwame Nkrumah, had anticipated his country's electricity needs and built a dam across the Volta river. As the surrounding countryside became flooded, hilltops became islands. Yet communities clung to these islands, and illiterate mothers kept their children's Road to Health charts beautifully wrapped in plastic, most of the cells not filled as the immunisation dates were missed.In response, the health administration, with World Health Organization (WHO) support, focused their attention on the Volta region with the ‘Reaching Every District’ (RED) approach. Selected districts were provided with funds and technical assistance to develop and implement micro-plans that covered outreach services, supervision and monitoring, social mobilisation, quarterly review meetings and other community activities in each of these remote communities. In addition, some districts received motorbikes and outboard motor boats to help them reach every island community and provide basic health services, including immunisation, vitamin A supplementation, de-worming medicines, and disease surveillance.At the global level, policies emphasise the need to reach the poorest. Examples include Millennium Development Goal 1: the reduction of poverty and hunger, and the UN Human Development Index, which measures health, education and living standards. The WHO has addressed neglect of populations and communities by focusing on social determinants of health, equality issues, universal coverage, a human rights approach to health and a return to the primary health care philosophy. Advocacy has achieved a global determination to eliminate neglected diseases.The first step towards bringing better health and eye health to neglected communities, is for eye care workers to familiarise themselves with national strategies for reaching neglected communities. The second step is to create a map of the area covered by the district eye health programme . This will help to identify hard-to-reach or particularly disadvantaged communities that must be prioritised.Eye health workers should look beyond just the eyes', and aim to be part of a campaign to take health into every home throughout the year. The trainers of eye health workers should ensure that they teach eye health workers about neglect in all its facets, its causes and its solutions, and the need to engage with other agencies working in health.


Our aim was to discuss, by presenting a case, the possibilities connected to the use of a CBCT exam in the dental evaluation of patients with Cleidocranial Dysplasia (CCD), an autosomal dominant skeletal dysplasia with delayed exfoliation of deciduous and eruption of permanent teeth and multiple supernumeraries, often impacted. We think that CBCT in this patient was adequate to accurately evaluate impacted teeth position and anatomy, resulting thus useful both in the diagnostic process and in the treatment planning, with an important reduction in the radiation dose absorbed by the patient. Cleidocranial dysplasia (CCD), also known as cleidocranial dysostosis or Marie-Sainton syndrome, is a disorder that affects most prominently those bones derived from endochondral and intramembranous ossification and it's characterized by defective development of the cranial bones and by the complete or partial absence of the clavicles. Diagnosis is based on clinical and radiographic findings, that include imaging of the cranium, thorax, pelvis and hands. Frequently these patients presents a delayed ossification of the skull fontanels and a premature closing of the coronal suture that leads to a frontal, parietal and occipital bossing of the skull; a short stature, occasionally accompanied by a spinal scoliosis; a wide and flat nasal bridge due to hypertelorism; different anomalies of pubis and hipbone, with flat feet and knock knees; a brachycephaly with an high arched palate and sometimes cleft palate; a prolonged retention of deciduous teeth and several impacted permanent successors and supernumerary elements, sometimes accompanied by follicular cysts and eruptive pseudocysts ,2. This Although the spectrum of phenotypic variability in CCD ranges from primary dental anomalies to all CCD clinical features plus osteoporosis, no clear phenotype-genotype correlation has been established .Children with CCD should be monitored for orthopedic complications, dental abnormalities, upper airway obstruction, sinus and ear infections, hearing loss, and osteoporosis.The most important dental problem associated with this syndrome is the malocclusion and the crowding of the dental arches caused by the retention of multiple deciduous teeth and the presence of several supernumerary. These supernumerary, associated with a diminished alveolar bone resorption, also lead to the impaction or the ectopic location of the permanent teeth ,7.The previous approach to the dental problems of these patients consisted in no treatment or in the extraction of the impacted or malformed teeth and their prosthetic replacement ,9, with In the last years a more conservative approach has been developed, combining orthodontics and maxillofacial surgery. Orthodontic treatment consist in the extraction of the supernumerary teeth and the deciduous with delayed exfoliation, followed by the surgical exposure of impacted permanent teeth and their orthodontic guided eruption. Extractions are not accomplished in one time: there must be a staged approach in order to maintain the vertical occlusal dimension while the different groups of unerupted teeth are exposed and pulled in their ideal position.If there isn't any, or just a mild, skeletal discrepancy between maxilla, mandible and cranium, the treatment is finished with the alignment of all permanent teeth, obtaining a correct occlusion and an agreeable smile aesthetics . They also show other features helping in the diagnostic process like the presence of impacted teeth, the underdevelopment of maxillary sinuses and the parallelism of mandibular ramus, with an upward and posteriorly pointing coronoid process .Unfortunately, especially when there are a lot of supernumerary teeth, traditional dental radiographs are not enough rich in details to allow correct planning the orthodontic treatment of patients in late mixed dentition.In these cases it's appropriate to use a multi-slice computed tomography (MSCT) scanner with an accurate tridimensional information regarding the anatomy of every single tooth, the spatial relation between adjacent teeth and face to the surrounding anatomical structures.These data are of crucial importance in order to perform the best orthodontic treatment for different reasons: they permit to surely identify the supernumeraries teeth, often with some hidden malformations like dilacerations or dental invagination; they give the exact position of the impacted teeth in relation to the roots of the adjacent erupted teeth, preventing damage of these roots during the forced orthodontic eruption of the impacted teeth; and they also define the position of every tooth inside the alveolar bone and near some important vascular vessels and nerve fibers, avoiding unexpected complications during the extraction or the surgical exposition of impacted teeth, like bone fracture, local hemorrhage or denervation.Unfortunately a conventional MSCT exam expose the patient to an high dose of x-ray, thereby limiting the application of this techniques only to the most complex cases.Recently a relatively new technique, the CBCT, reducing the dose of radiation adsorbed by the patient, had been improved by different manufacturer, obtaining good quality images. The principal difference between MSCT and CBCT is that conventional CT uses a fan of x-rays and a narrow detector, so multiple slices are stacked to obtain a complete image, whereas CBCT use a cone of x-rays and a two-dimensional square detector allowing a single rotation of the radiation source to capture an entire region of interest: hereby the total radiation is less important than with conventional CT .A 15-year-old man, with a diagnosis of Cleidocranial dysplasia, was referred to our department for orthodontic treatment. The patient was previously treated only with deciduous and supernumerary teeth extraction and four panoramic x-ray were taken in the last two years in order to check teeth development and eruptive direction Figure , 3, 4.Old radiograms examination shows the presence of several supernumeraries and impacted teeth: we were able to estimate the number of impacted teeth but it was not possible to exactly evaluate their morphology, in order to detect possible root reabsorption areas and to establish which were supernumeraries teeth and which not, and their anatomical relationship with other teeth and with some critical structures like mandibular nerve and foramen.On the basis of these findings a three-dimensional CBCT scan was obtained, in order to exactly recognize teeth anatomical anomalies, to decide which of them are to be extracted and to plan the surgical access.We decided to use the NEWTOM 3G  scanner and we choose the spherical field of view (FOV) of 9" (medium FOV) in order to obtain an image of only maxillary, mandibular and TMJ region with a unique acquisition. The scan was completed within 36 seconds and the time of exposure was of 3,6 seconds. The tube voltage was of 110 kV and the tube current was of 4,70 mA.We used the 2.11 version of the QR NNT program to visualize the most interesting axial sections showing the impacted and the supernumerary teeth Figure .Afterward we selected a limited area of the volume acquired Figure , 7 and wWe also utilized the dynamic 3D function in order to obtain a panoramic overview of the intermaxillary dental relationship Figure .Images analysis showed the presence of three supernumeraries - between 3.2 and 3.3 Figure , 11, 3.3Sections from 6 to 14 in figure nr. Sections from 21 to 24 in figure nr. Figures nr. Figure nr. The use of 3D computer assisted tomography is the best, and probably the only one, method permitting to elaborate a real individual orthodontic treatment plan for each CCD patient. It allows to precisely locate the impacted or ectopic teeth and therefore to perform a minimally invasive surgery and to plan the most effective orthodontic strategies ,18.Therefore CT images permit to safely place titanium screw, that have been suggested by Kuroda  to be veThe shortcoming of the routinely use of this technique was related to the high radiation exposure of the patient, limiting the application only at complex cases. All other cases were studied with traditional dental radiology using the tube shift method , that taking two conventional radiographs permit to locate the impacted tooth location comparing the movement of this tooth respectively to the way in which the radiograph was taken.Rosenstein , using aEricson and Kurol  documentThis dichotomy between conventional radiology and computed tomography can be overcome utilizing a CBCT system, that permit to obtain an accurate 3D reconstruction and several sagittal, frontal and axial view of the impacted tooth, with a radiation exposure level that lay between multi slice CT (MSCT) and conventional radiography . Of courTherefore we utilized in this case report the medium NewTom 3G FOV of 9" that, with an effective dose lower than the large FOV of 12" (indicated by Ludlow as administering a lower effective dose face to the most of the others CBCT scanners included in his study), permits to perform a three-dimensional study of: the upper airways ; the temIn CCD patients the use of reconstructed 3D images obtained by a CBCT exam for diagnosis and treatment planning has only scarcely been documented until now, so no evidence-based conclusion can be made based on the current literature. CCD diagnosis is frequently made during the early childhood or even at birth, consequently it's incorrect to state that CBCT could be useful in identifying CCD. On the other hand, there is a general agreement that 3D images allows to obtain a more accurate reconstruction of the real anatomy than traditional 2D radiologic images, really useful especially in patients with impacted and supernumeraries teeth like CCD ones, even if there is no agreement about an extensive use of CT exams.We present this case report to support the use of a less invasive CT exam, the low dose CBCT technology, in CCD patients in late mixed dentition undergoing orthodontic treatment and to promote the collection of sufficient data to come to a common agreement on the use of 3D radiological exam in these patients.Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.The authors declare that they have no competing interests.All authors read and approved the final manuscript. DD conceived of the study, and participated in its design and coordination and helped to draft the manuscript. LL has been involved in drafting the manuscript and to collect the results from follow-up examinations. MP has been involved in revising the manuscript critically for important intellectual content. CP and PB have done substantial contributions to conception and design and interpretation of data.


Planctomycetes, Verrucomicrobia, and Chlamydiae, along with the Lentisphaerae, Poribacteria, and two other candidate divisions. The diverse species of this superphylum lack any significant marker that differentiates them from other bacteria. Recently, genome sequences for 37 species covering all of the main PVC groups of bacteria have become available. We have used these sequences to construct a phylogenetic tree based upon concatenated sequences for 16 proteins and identify molecular signatures in protein sequences that are specific for the species from these phyla or those providing molecular links among them. Of the useful molecular markers identified in the present work, six conserved signature indels (CSIs) in the proteins Cyt c oxidase, UvrD helicase, urease, and a helicase-domain containing protein are specific for the species from the Verrucomicrobia phylum; three other CSIs in an ABC transporter protein, cobyrinic acid ac-diamide synthase, and SpoVG protein are specific for the Planctomycetes species. Additionally, a 3 aa insert in the RpoB protein is uniquely present in all sequenced Chlamydiae, Verrucomicrobia, and Lentisphaerae species, providing evidence for the shared ancestry of the species from these three phyla. Lastly, we have also identified a conserved protein of unknown function that is exclusively found in all sequenced species from the phyla Chlamydiae, Verrucomicrobia, Lentisphaerae, and Planctomycetes suggesting a specific linkage among them. The absence of this protein in Poribacteria, which branches separately from other members of the PVC clade, indicates that it is not specifically related to the PVC clade of bacteria. The molecular markers described here in addition to clarifying the evolutionary relationships among the PVC clade of bacteria also provide novel tools for their identification and for genetic and biochemical studies on these organisms.The PVC superphylum is an amalgamation of species from the phyla  The bacteria of the Planctomycetes, Verrucomicrobia, Chlamydiae, and Lentisphaerae phyla along with the Candidate Poribacteria, Candidate phylum OP3 and Candidate division WWE2 are collectively grouped and referred to as the PVC superphylum or the PVC clade  or conserved signature proteins (CSPs) have been extensively used to define taxonomic clades of different phylogenetic ranks in molecular terms  for studying closely related organisms , which we will refer to as the Opitutae clade, was comprised of the species O. terrae, Diplosphaera colitermitum, Coraliomargarita akajimensis, Opitutaceae bacterium TAV5, and TAV1 and also Verrucomicrobiae bacterium DG1235. The first five of these species/strains belong to the class Opitutae, whereas V. bacterium DG1235 is currently a part of the class Verrucomicrobiae  were part of the second major clade where they branched with Chthoniobacter flavus, a member of the class Spartobacteria and Methylacidiphilum infernorum, an unclassified species belonging to this phylum  brasiliensis, Pl. limnophilus, Pl. maris, Rhodopirellula baltica and Singulisphaera acidiphila. The nine species of the Planctomycetales order, as expected, branched together in the tree. However, in conflict with the established placement of K. stuttgartiensis within the class Planctomycetia, this species was observed as the deepest branching member of the phylum with Ph. mikurensis sharing a closer relationship to the species of the Planctomycetales order. The deeper branching of the anammox species (viz. K. stuttgartiensis) in comparison to Phycisphaera has also been observed in earlier studies  whose sequence was available at that time  was identified that in addition to the sequenced Chlamydiae species was also exclusively present in one Verrucomicrobia species  whose length varies from ∼53 aa in the Chlamydiaceae to more than 80 aa in the Planctomycetes. In BlastP searches with the C. trachomatis homolog all of the observed hits for this protein are for the PVC group of species and no hit outside of this group is observed. The 53 aa long region of this chlamydial protein is well conserved in all sequenced species belonging to the PVC clade and a sequence alignment for this region is presented in Figure Our detailed analysis identified no CSI that was specifically shared by all or most of species from the PVC phyla of bacteria. However, we have identified one signature protein, whose specific presence in various species belonging to the PVC clade suggests that the species from the four main phyla might be specifically related. The protein of interest is a hypothetical protein . The anammox organisms such as K. stuttgartiensis possess a number of distinctive features such as the presence of an ammonium oxidizing organelle called the anammoxosome and cell division by constrictive binary fission, which differentiate them from other members of the class Planctomycetia  that comprise the PVC clade of bacteria in molecular terms. The specificities of these markers for the species from these clades provide independent evidence for the monophyly of these clades. Additionally, based upon these molecular markers a number of relationships within these bacterial phyla can also be consolidated. Within Verrucomicrobia, newly identified CSIs allow the species from the class Opitutae and family Opitutaceae to be distinguished in molecular terms. The species distribution of these CSIs strongly indicate that the species More importantly, in the present work, we have also identified some signatures that are helpful in clarifying how the species from the PVC phyla of bacteria are related and providing some evidence supporting their amalgamation into larger clades. However, only a couple of signatures that are helpful in this regard were identified. The most significant of these signatures is a 3 aa long insert in the RpoB protein that is commonly and uniquely shared by all of the sequenced Chlamydiae, Verrucomicrobia, and Lentisphaerae species but not found in any other bacteria. The observed species specificity of this signature, in this important protein, strongly indicates that the species from these three phyla shared a common ancestor exclusive of all other bacteria. The RpoB protein also contains a number of other CSIs in other regions of the protein that are specific for other groups/phyla of bacteria  of sequences from various species from these groups. Additionally, blast searches with the sequence queries based upon these proteins also provide useful identification tools for detection of both known and unknown species from these phyla in metagenomic sequences. Finally, the identified CSIs and CSP provide novel tools for genetic and biochemical studies and functional studies on them could lead to discovery of novel biochemical and/or physiochemical properties that are commonly shared by these phyla or the PVC clade of bacteria.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Prior to the publication of the book reviewed here, the only books dealing specifically with fossil spiders have been primarily taxonomic monographs, such as those on Dominican and Baltic amber inclusions by , 2004, oThe book begins with an introduction to spiders from a palaeontological perspective, putting their geological longevity into context of the other known fossil and extant arachnid orders, including comparative data for numbers of described extant and fossil species for all orders. The relative diversity of spider sub-orders today is compared with that of the past. The authors provide reasoned support for the importance of fossil spiders in addressing large-scale palaeobiological questions on a global scale, and over long periods of time, including how information on past changes in biogeographical distributions can be correlated with changes in palaeoclimatological factors and the potential of this for predicting the consequences of current climate change. Information is also provided on how the fossil spiders are dated.PageBreakThe fossil record of spiders is discussed with regard to non-amber fossils , including the different modes of preservation with photographic examples (often of holotypes) throughout. The amber spider fossil record follows a similar format with a table of 42 important localities. There is also a section on fossilized spider silk. An important aspect of interpreting fossil assemblages is an understanding of bias in the fossil record and this is covered for both amber and non-amber deposits.PageBreak It includes techniques for preparing both amber and non-amber fossils, including how to obtain the best photographs, and also the application of new imaging techniques which allow non-destructive digital dissection of the fossils, such as x-ray computed and synchrotron technology. The images included here are quite exceptional. This is followed by a discussion of the problems associated with identifying and naming fossil spiders, particularly in a neontological context, including critical examples of techniques recently proposed to assist in this process.Next follows a highly informative chapter on techniques for the preparation and study of fossil spiders, which will be of great use for new students of palaeoarachnology.There is a chapter on the strictly fossil spider families, which lists all known species and their deposit of origin.The taxonomic status of each family is discussed and it is noted that many are in need of revision. Again, this section includes good photographs including of holotypes.Approximately half way through, the focus of the book switches from understanding and interpreting the fossil spiders to the application of the palaeontological data. Much use is made of the spider evolutionary tree, which was created by superimposing the cladogram of Araneae over the geological time scale and calibrating it with described fossils. This tree is up-to-date and even includes the recently erected family Penestomidae and the recent synonymy of Microphocommatidae with Anapidae. There is a handy table referencing the oldest fossil of each of the 73 extant spider families known in the fossil record, used to create the evolutionary tree. Topics in this section include originations and radiations , mass extinctions, and predator-prey co-radiations, including updated analyses (based on new data) of previously published work by the authors.The last chapter concerns how fossil spiders can contribute to our understanding of past and present biogeography. The authors present some rather remarkable examples of disjunct distributions between the fossil and extant spider faunas. A table of spider family distributions over time, including recent, Cenozoic and Mesozoic distributions presents the available data in a user-friendly fashion. Importantly, the authors note that it is just as important to look at which families do not appear in the fossil record and provide a table of data for these also, and discuss possible reasons for their exclusion. The book ends with a comprehensive reference section of some 265 entries and an index to family citations. There is a handy reference figure of the geological timescale on page 6.In conclusion, this is an absolutely unique book in the spider literature to date. It is authoritatively written by two of the leading researchers in this field and provides broad coverage of their combined 50 years experience and expert knowledge. The book is hard back and presented on high quality glossy paper. It is richly illustrated thoughout by numerous high quality photographs of fossil spiders. In conclusion, this book deserves a place on the shelves of the libraries of all professional and amateur arachnologists alike, in addition to those of invertebrate palaeontologists.http://www.siriscientificpress.co.ukThe book can be ordered via the author: by emailing siri.press@live.co.uk. Price £32.00 plus post and packing. For further details, including ordering online, etc. visit


The United States National Physical Activity Plan , the country’s first national plan for physical activity, provides strategies to increase population-level physical activity to complement the 2008 physical activity guidelines. This study examined state public health practitioner awareness, dissemination, use, challenges, and recommendations for the NPAP.In 2011–2012, we interviewed 27 state practitioners from 25 states. Interviews were recorded and transcribed verbatim. Transcripts were coded using a standard protocol, verified and reconciled by an independent coder, and input into qualitative software to facilitate development of common themes.NPAP awareness was high among state practitioners; dissemination to local constituents varied. Development of state-level strategies and goals was the most frequently reported use of the NPAP. Some respondents noted the usefulness of the NPAP for coalitions and local practitioners. Challenges to the plan included implementation cost, complexity, and consistency with other policies. The most frequent recommendation made was to directly link examples of implementation activities to the plan.These results provide early evidence of NPAP dissemination and use, along with challenges encountered and suggestions for future iterations. Public health is one of eight sectors in the NPAP. Further efforts are needed to understand uptake and use by other sectors, as well as to monitor long-term relevance, progress, and collaboration across sectors. A high prevalence of physical inactivity and resulting harmful health effects, coupled with evidence for effective promotion strategies  make phyThe NPAP outlines population-based strategies to increase physical activity across eight sectors . The secGuidance is lacking on best practices for dissemination of evidence-based physical activity interventions, particularly with a focus on policy. Moreover, dissemination of national plans is often not evaluated . Therefohttp://www.census.gov/geo/www/us_regdiv.pdf). Interviews were conducted between July 2011 and March 2012. While we did not select states by whether or not they had a state wide plan that included physical activity, at the time of the interviews all states in the sample had a state wide plan with a focus on physical activity, usually within an obesity or chronic disease prevention plan.Interviews were conducted with either the lead state physical activity practitioner, as designated by the Centers for Disease Control and Prevention (CDC), or the person at the state health department most knowledgeable about the organization’s physical activity promotions and programs. To obtain geographic representation, we emailed and telephoned people in a convenience sample of states from each of four US census regions  framework  and DiffTwenty-three interviews were conducted over the telephone and two were conducted in person. Two telephone calls included two people interviewed simultaneously. A fact sheet and copy of the interview questions were sent beforehand. Verbal consent was obtained at the start of the interview. All but one interview was recorded and transcribed verbatim. One participant declined to be recorded; therefore, detailed notes were taken.The codebook, initially developed from the interview guide, was expanded with new codes that emerged during the coding process. It consisted mainly of deductive codes generated from the research questions and interview guide. Additionally, both uses and challenges were coded using characteristics that tend to promote higher diffusion, including compatibility, evidence-based, complexity, flexibility, risk, trialability, reversibility, observability, implementation, cost, and relative advantage . As parthttp://www.nspapph.org/).Twenty-seven state public health practitioners were interviewed, representing 25 states in each of four US regions . Among the sample, 19/27 were members of the National Society of Physical Activity Practitioners in Public Health (NSPAPPH), a professional organization of physical activity practitioners in public health  by connecting strategies and tactics in the plan to exemplary programs.Respondents were asked to provide suggestions to improve future iterations of the NPAP Table . The mosOther more frequent suggestions were to create shorter synopsis documents for each sector, and tools to communicate with partners outside of public health. One respondent suggested providing work plan examples that correspond to plan tactics with SMART criteria   for futuApproximately half of the state-level practitioners were aware of the companion implementation plan titled “Make the Move: 2010–11 National Implementation of the US Physical Activity Plan” . One resInterviews with state public health practitioners provided insights into the initial awareness, dissemination, uses, challenges, and future recommendations for the NPAP since its launch in 2010. Applying the RE-AIM framework , we founDissemination of the NPAP through state practitioners to local health departments and coalitions was inconsistent. Among those who disseminated the NPAP locally, most did so only one time. Yet, the interviewees had high awareness of the plan and served as state wide contacts for local practitioners, making state practitioners a possible conduit to communicate with local practitioners. Given that there are 59 state and territorial health departments and more than 3000 local health departments in the US , state-lhttp://www.thecommunityguide.org) [http://www.ctb.ku.edu/en/default.aspx). Development of a national-level document that summarizes the critical reports, guidelines, and tools pertaining to physical activity, and electronically linking to each of them for easy access, may help facilitate a better understanding of the guidance and resources available and how best to use and distinguish among them from one another.Most respondents either were not aware of the companion implementation plan or had rarely or never used it. This lack of use was evident in suggestions to connect the NPAP’s strategies and tactics directly to implementation examples. This finding demonstrates a significant opportunity to enhance NPAP implementation. It may be useful to bundle the documents and resources together, to facilitate connecting a strategy or tactic to implementation guidance. More broadly, there was confusion by a few respondents about overlap in several major physical activity documents, including the NPAP and its implementation plan, the 2008 Physical Activity Guidelines for Americans , the Guiide.org) , and theA 2010 survey of NSPAPPH members corroborated several findings from these interviews . The surThe Diffusion of Innovations theory suggests that specific attributes may contribute to the speed or extent that an innovation is disseminated ,26,27. AThe most frequent positive use of the NPAP was as a reference to development of state-level goals. To enhance use of the NPAP instead as a direct guide for state-level planning, new materials could describe how to use the national plan, particularly for states updating their health-related plans or developing stand-alone physical activity plans . Other rInstrumental use occurs when research evidence is directly applied to decision-making, such as using the NPAP to assist with development of state plans. Conceptual use refers to situations in which research evidence influences how practitioners think about issues, problems, or potential solutions. For the NPAP, several respondents mentioned that learning from non-traditional sectors (transportation) influenced their thinking. Tactical, political, or symbolic use occurs when research evidence is used to justify particular positions, such as the NPAP validating their own plans or work. The final use, imposed use, is defined as situations in which there are mandates to use research evidence, such as when government funding requires practitioners to choose strategies from the NPAP. The authors note that the typology is not exhaustive, nor mutually exclusive, but demonstrates how research evidence (in our case the NPAP) serves multiple purposes and is used in multiple ways.A typology for using research evidence in practice can be applied to also help illustrate how the NPAP is being used . InstrumIn the US, this is the first national-level plan to focus exclusively on physical activity, though national plans exist for a number of related health behaviors and diseases, such as tobacco control , diabeteProviding short synopses of different sections to assist users in digesting information, particularly for those only interested in one sector in the case of the NPAP.Using diverse communication channels to distribute the plan and to provide regular plan updates to maintain awareness and increase use of the plan.Linking implementation strategies and examples to the plan.Grouping strategies by cost and impact into high, medium, and low categories.http://www.communitycommons.org/) where information can be shared and professionals from different sectors with similar interests can connect.Offering two-way communication  to enhance dissemination . For exaDeveloping a national-level document that summarizes the critical reports, guidelines, and tools pertaining to physical activity together, and electronically linking to each of them for easy access, to facilitate an understanding of the guidance and resources available and how best to use and distinguish among them.We gathered perspectives from state public health practitioners about their awareness and use of the NPAP. The sample included broad geographic coverage, with half of all states represented. We met our goal number of interviews across census regions; however, it is unclear whether respondents were more likely to be familiar with and use the NPAP than those who did not participate. Despite the geographic representation, the absolute sample size limited our ability to explore regional variations. Moreover, awareness of the NPAP may have been over reported, since interview questions were sent to participants prior to the interview.There are substantial challenges in translating scientific evidence into meaningful public health programs and policies . CurrentInterview questions for this study About Your Job(1) Please state your job title and describe your role.(2) In what city and state do you work?(3) How long have you been in this role?About You and the National Physical Activity Plan(4) Have you heard of the National Physical Activity Plan?(5) In what context did you learn about the Plan?(6) Have you provided feedback on the Plan to the National Physical Activity Plan Group since it was published in 2010?(7) Have you participated at the national level with any of the sector committees, either before or after the National Physical Activity Plan was published?(8) Since learning about the Plan, have you used it in your work?(9) What parts of the Plan are most useful to you and your work? Have any positive changes occurred?(10) Are there any difficulties you have had in using the Plan?(11) Describe in detail the challenges you have had in working with the Plan.(12) What supplementary materials or activities would make the Plan more useful to you and your work?(13) Do you have any ideas for how the Plan content or structure could be made more useful to you and your work? For example, what would you like to have in the Plan that is not in it currently?(14) Have you shared the plan with others in your state?About Your Organization and the National Physical Activity Plan(15) Is the leadership at your organization familiar with the Plan?(16) Are those you identify as the intervention or programmatic staff where you work familiar with the Plan?(17) Did the Plan change your organization’s activities at the state or local level?(18) Have staff scheduled periodic assessments of how the Plan is used in organizational planning and activities?About Your State and Local Uses of the National Physical Activity Plan(19) Are you aware of the Plan being used at the local level in your state?(20) Does your state currently have a physical activity related state plan?Implementation Plan(21) Are you familiar with the national implementation plan ? The publication is titled “Make the Move: 2010–2011 National Implementation of the U.S. Physical Activity Plan”.Other Questions(22) Can you tell me of other colleagues, and their affiliations, in your state working with the National Physical Activity Plan that we may want to interview?(23) Do you have any additional comments to share before we end the interview?CDC: Centers for Disease Control and Prevention; NPAP: National Physical Activity Plan; NSPAPPH: National Society of Physical Activity Practitioners in Public Health; RE-AIM: Reach Effectiveness Adoption Implementation Maintenance; SMART: Specific Measurable Achievable Realistic Timely; US: United StatesThe authors declare that they have no competing interests.KRE oversaw the development of the study, the drafting of the interview guide and procedures, the analysis of the transcripts, and drafted the article. All coauthors assisted with the development of the interview guide, assisted with coding and analyzing the transcripts, reviewed the article several times, and gave final approval for its submission. In addition, SBS, CV, IH, SPH, HLR, and NOT conducted interviews. All authors read and approved the final manuscript.


Systematic reviews and meta-analyses of home telemonitoring interventions for patients with chronic diseases have increased over the past decade and become increasingly important to a wide range of clinicians, policy makers, and other health care stakeholders. While a few criticisms about their methodological rigor and synthesis approaches have recently appeared, no formal appraisal of their quality has been conducted yet.The primary aim of this critical review was to evaluate the methodology, quality, and reporting characteristics of prior reviews that have investigated the effects of home telemonitoring interventions in the context of chronic diseases.Ovid MEDLINE, the Database of Abstract of Reviews of Effects (DARE), and Health Technology Assessment Database (HTA) of the Cochrane Library were electronically searched to find relevant systematic reviews, published between January 1966 and December 2012. Potential reviews were screened and assessed for inclusion independently by three reviewers. Data pertaining to the methods used were extracted from each included review and examined for accuracy by two reviewers. A validated quality assessment instrument, R-AMSTAR, was used as a framework to guide the assessment process.Twenty-four reviews, nine of which were meta-analyses, were identified from more than 200 citations. The bibliographic search revealed that the number of published reviews has increased substantially over the years in this area and although most reviews focus on studying the effects of home telemonitoring on patients with congestive heart failure, researcher interest has extended to other chronic diseases as well, such as diabetes, hypertension, chronic obstructive pulmonary disease, and asthma. Nevertheless, an important number of these reviews appear to lack optimal scientific rigor due to intrinsic methodological issues. Also, the overall quality of reviews does not appear to have improved over time. While several criteria were met satisfactorily by either all or nearly all reviews, such as the establishment of an a priori design with inclusion and exclusion criteria, use of electronic searches on multiple databases, and reporting of studies characteristics, there were other important areas that needed improvement. Duplicate data extraction, manual searches of highly relevant journals, inclusion of gray and non-English literature, assessment of the methodological quality of included studies and quality of evidence were key methodological procedures that were performed infrequently. Furthermore, certain methodological limitations identified in the synthesis of study results have affected the results and conclusions of some reviews.Despite the availability of methodological guidelines that can be utilized to guide the proper conduct of systematic reviews and meta-analyses and eliminate potential risks of bias, this knowledge has not yet been fully integrated in the area of home telemonitoring. Further efforts should be made to improve the design, conduct, reporting, and publication of systematic reviews and meta-analyses in this area. The prevalence of chronic diseases such as diabetes, cardiovascular, and respiratory conditions continues to pose a significant and longstanding challenge for virtually all health care systems, requiring fundamental changes in the management and delivery of patient care -3. Home Over the years, in the context of national eHealth strategies in Europe, Canada, Australia, the United States, and other parts of the world, there have been numerous efforts and research initiatives to examine the effectiveness of HT for patients with chronic diseases as a potential cost-saving approach eg, ,9). The . The 9])Systematic reviews (SRs) and meta-analyses (MAs) are powerful research tools that have been established in the health sciences, and more recently in the medical informatics field, as the cornerstone of evidence-based practice ,15. TheyHowever, the quality and internal validity of SRs and MAs depend on many aspects pertaining to the conduct of the review and the quality of empirical studies selected for inclusion. Flaws and deficiencies in the methods concerning the bibliographic search, selection, appraisal, and synthesis of evidence can lead to invalid conclusions with significant implications for patient care and decision makers. Hence, researchers have proposed and adopted evaluation tools that allow a close examination of the methodological rigor of reviews in several clinical areas eg, -21)..21]).Reviews focusing on HT interventions for patients with chronic diseases have increased over the past decade. While a few criticisms about their methodological rigor and approaches have recently appeared  studies that involved the use of information and communication technologies by patients for the timely transmission and remote monitoring of vital signs , biometric, and disease-related data  from the patients’ residence to a clinician  at a health care service center. SRs that investigated and combined collectively  the effects of HT with other stand-alone multidisciplinary interventions of remote patient monitoring  were excluded.Prior reviews were included only if primary or secondary outcomes from the primary studies pertaining to the clinical, structural , behavioral , or economic effects of HT were synthesized and presented. Reviews that focused on other aspects such as the technical feasibility of HT modalities were excluded.We performed a literature search on Ovid MEDLINE, the Database of Abstract of Reviews of Effects (DARE), and Health Technology Assessment Database (HTA) of the Cochrane Library (from 1966 to December 2012) in order to identify all relevant reviews. On the Cochrane Library, we conducted the search using four keywords . On Ovid MEDLINE, we used the same keywords in conjunction with each of the following terms: systematic review, meta-analysis, and review. Language restrictions were not applied to any of the searches.As shown in One reviewer (SK) extracted explicit details from each review in a nonblinded manner by using an electronic extraction form that was developed for the purposes of this study. All extracted data were examined for accuracy by 2 of the reviewers (GP and MJ), and any disagreements were reconciled through consensus. The information sought included general details pertaining to the characteristics of the reviews  and more specific details about the use and interpretation of methods for synthesizing the available evidence .The methodological quality of the 24 reviews was appraised independently in a nonblinded format by 2 reviewers (SK and GP) using the Revised Assessment of Multiple Systematic Reviews (R-AMSTAR) instrument . Any disAs shown in Journal of Telemedicine and Telecare (n=3), Telemedicine and e-Health (n=3), and the Journal of Evaluation in Clinical Practice (n=2). Five reviews )Based on our assessment, we found that with the recent increase in reviews of HT interventions an important number of these articles appear to lack optimal scientific rigor due to intrinsic methodological issues. Furthermore, their overall quality does not appear to have improved over time. Despite the wide availability and dissemination of important methodological guidelines ,81 that Although the majority of reviews used more than 2 electronic databases to search for relevant studies, other important approaches to minimize bias and enhance the search strategy were rarely used. Only 2 reviews attempted to identify primary studies in the gray literature and the vast majority restricted all searches to English articles only, although it has been demonstrated that bias can be introduced in SRs and MAs focusing exclusively on English language publications ,83. InclHT as a research area has witnessed considerable growth over the past decade. Nevertheless, from a conceptual point of view there seems to be a lack of consensus between authors of SRs and MAs in the terminology they used  of the review require thoughtful consideration, as well as clinical judgment and should be based on explicit clinical and methodological criteria that minimize subjectivity as much as possible . Based oP values, which have a notorious record for being misleading, particularly in situations with small primary studies that have large within-study variance  and are not sufficiently powered to reach significant results [P values.Authors employing narrative or qualitative synthesis should describe explicitly the analysis plan underpinning each stage of the evidence synthesis process, in order to clarify and support the logic that was used to reach the final conclusions. Presenting an analysis plan is of paramount importance and should be an integral part of the Methods section in future SRs of HT, as it clarifies the synthesis process, improves the transparency and reliability of the review, and acts as a safeguard against bias that can arise from placing inappropriate emphasis on the results of one study over another -89. Such results . Given t results ) rather 2, or both heterogeneity statistics in most cases. This was particularly encouraging and reflects a good practice that is generally consistent with other MAs in the health care domain [2 point estimates, which can be expressed with 95% confidence intervals, were not considered in any of the included MAs. As a result, firm claims or inferences about the extent of inconsistencies in the HT effects between trials in most cases were stronger than the evidence allowed. Perhaps this limitation can be attributed to the fact that the Review Manager (RevMan) software, which was used in more than half of the MAs, does not provide users with a functionality to calculate the confidence intervals of I2. This is an issue that has also been highlighted by other researchers and communicated in hope that future updates of this software will make confidence intervals an integral part of I2 heterogeneity calculations [One of the main objectives of the statistical methods used in MAs of HT interventions is to evaluate the dispersion among the results of the included studies, that is, the between-study heterogeneity in effect sizes, in order to assess the consistency of study findings. In light of observed heterogeneity, it is important to investigate and explain, whenever possible, what is causing it in order to increase scientific understanding and clinical relevance. With respect to the first goal, all 9 MAs included in our sample adhered closely to recommended guidelines and assessed formally the variability (heterogeneity) of the HT studies’ results by calculating either Cochran’s Q, Ie domain . Howevere domain -67,70,71ulations .2 is not precise and hence, confidence intervals for I2 estimates should always be reported and interpreted carefully, as they are valuable for reflecting the uncertainty associated with the estimated ratio of true heterogeneity to total variation in the observed effects [2 estimate should be interpreted with caution and any strong statements about the consistency of the observed HT effects “should be avoided or tempered appropriately, regardless of the results” [Future MAs in this area should continue to use both statistics to measure the statistical significance and proportion of heterogeneity in the observed effects. However, the limitations of these metrics must be taken into consideration. The Q statistic is subject to the same caveats as all tests of significance and should always be interpreted with due caution based on the number of HT studies included in the analysis . The I2  effects . When thresults” . Furtherresults” ,38), thiresults” .When combining data from various HT studies, a major dilemma is to decide whether to perform a fixed or random effects meta-analysis. This decision is particularly important as the choice of model might affect the estimate of the effect size and, ultimately, the interpretation of the results ,90. A fi2>30%) to substantial  statistical heterogeneity in the observed effects. The use of a fixed rather than a random effects model influenced their results, as it produced tighter confidence intervals and spuriously low levels of statistical significance for the effects of HT. Specifically, in the Cochrane review the effect estimate for all cause-hospitalization using the fixed effect model showed a statistically significant (P=.02) reduction of 9% favoring HT . Whereas the random effects model yields a nonsignificant (P=.22) effect size of the same magnitude with a wider confidence interval , reflecting the uncertainty behind the positive effects of HT on average. Similarly, in the MA by Clarke et al [P=.02) reduction of deaths by 23% in favor of HT . However, the random effects model yields a more conservative and nonsignificant (P=.30) effect-size of 17% on average with wider confidence interval , reflecting again that the underlying effect of HT may not always be positive across all patients and contexts. Given the clinical and methodological differences of the HT trials included in these 2 MAs, the use of the fixed effect model appears to be counterintuitive and the a priori assumptions that led to its selection should have been revisited, especially after the detection of statistical heterogeneity [Our evaluation revealed that the random effects model, which facilitates a broader outlook as it summarizes the distribution of the intervention effects across studies, appears to be the most preferable statistical model among MAs of HT interventions. Indeed, from a clinical perspective, the “one size fits all” approach of the fixed effect model appears to be difficult to justify. The participants and contextual characteristics of HT interventions in most cases differ in many practical ways that may have an impact on the results . It is ike et al , the effogeneity . Future ogeneity ,91, as wogeneity  in our sIf we apply the critical review approach to our own review, we realize that a number of challenges were faced in the process of appraising the methodological quality of the included SRs and MAs, which may have in turn affected our findings. First, our appraisal was performed on the basis of the information reported, explicitly or implicitly, in each review. Therefore, as in all methodological quality or risk of bias assessments, the accuracy of the judgments made by the evaluators relies heavily on the reporting adequacy of the reviews. It is possible that the authors conducted their review more rigorously. However, being aware of the length restrictions imposed by the journals and in light of competing demands for reporting the main findings of their review, they might have decided to omit some methodological information that was perceived as subtle or less important to report. It is also possible that the peer-review process itself resulted in abbreviating the text to meet space limitations. One recommendation for future reviews to alleviate this issue is to provide essential details about the protocol of the review in an electronic version, as is the practice in several peer-reviewed journals today, to aid in understanding the systematic review process considered. On the other hand, peer-reviewed journals that have an interest in publishing SRs and MAs in the area of HT should devote space for publishing online supplementary material and adopt appropriate mechanisms for flagging problems with and allowing corrections of previous work, once errors or other important deficiencies have been identified . Also, tSecond, it is important to note that the findings of our evaluation are confined to the reviews that met our inclusion criteria described in the Methods section. Although our bibliographic search identified several “narrative reviews” that focus on the effectiveness of HT interventions on patients with various chronic diseases, when these were not self-identified as systematic or did not feature essential properties of an SR or MA, they were excluded from our study. This strict selection process may have contributed to an overestimation of the methodological quality of HT reviews as reflected by the R-AMSTAR instrument and our analysis. Also excluded were several reviews that provided an all-inclusive and mixed overview of HT interventions along with various other “remote monitoring” interventions , but did not make a clear distinction between them in the analysis of the results. Therefore, our findings are not generalizable to reviews in which HT was one among many other multidisciplinary interventions of remote patient monitoring, although most would agree that the highlighted methodological deficiencies have significant relevance and are applicable to these reviews as well.This study is the first attempt to evaluate the overall quality of prior SRs and MAs of HT interventions. The comprehensiveness of the search strategy used to identify relevant reviews, the duplicated process in relation to study selection, data extraction, and quality appraisal, as well as the use of a validated instrument that offers the ability to conduct an in-depth quality assessment, are key indicators of the methodological soundness of the present study.The number of published SRs and MAs in the area of HT has substantially increased in the last decade offering to a wide range of health care stakeholders an extensive base of “large-scale evidence” from the synthesis of multiple primary studies on the clinical, behavioral, structural, and economic effects of HT for patients with chronic conditions. Yet, despite the significant body of knowledge that has been developed, wide acceptance by payers and care providers and integration of HT as an effective patient management approach remains problematic. This is mainly because the existing knowledge base still exhibits several important methodological weaknesses and research gaps.Of utmost importance, our critical assessment revealed that the overall quality and rigor of existing SRs and MAs of HT interventions is highly variable, with no signs of improvement over time. An important number of reviews contain several common methodological shortcomings that impair their internal validity and limit their usefulness for clinical, educational, research, and policy purposes. As a result, a range of questions regarding the effectiveness of HT for chronic disease management remain unanswered, including which is the ideal and most effective combination of case management and remote monitoring, which behavior change techniques and modalities are most effective, whether the effectiveness of interventions is influenced by participant demographics and settings, and whether HT is an effective and viable solution from an economic point of view. We thus recommend that future reviews in this area improve their overall rigor as well as their reporting aspects by adhering closely to available methodological guidelines. More precisely, they should at least include the following elements: (1) clearly stated research question(s) explicitly describing the patient population, intervention, comparison intervention, and outcomes; (2) comprehensive and clearly stated search strategies; (3) formal appraisal of the validity of the primary studies  with appropriate attempts to explore the impact of studies with high risk of bias on the estimated effects of HT; and (4) more rigorous methods of data synthesis with transparent descriptions and justifications of the techniques or statistics used.To conclude, it is our hope that this study will contribute to increase the overall quality of SRs and MAs in the HT area, as well as in the broader telehealth domain, by helping authors minimize diverse risks of biases and avoid previous methodological deficiencies. Nonetheless, we believe that building more rigorous and stronger evidence in the HT area will require unprecedented efforts by researchers, clinicians, funders, journal editors, and peer reviewers. Such efforts include but are not limited to the involvement of individuals with both clinical and methodological expertise in the conduct of SRs and MAs; amendments to the general instructions published by the journals with specific guidelines or links to methodological and reporting recommendations; the involvement of individuals in the peer-review process with prior experience and knowledge in the methodologies of SRs and MAs; and adoption of mechanisms to allow updates or corrections of online published material to address important deficiencies or even errors identified after publication.