Mexican migrant and seasonal farmworkers in the US-Mexico border region face health hazards and occupational risks and are becoming commonly known in the public health literature. According to several studies, farmworkers have high levels of chronic diseases such as diabetes and respiratory problems, are at risk for infectious diseases, and experience among the highest incidences of work-related injuries of any profession. The findings from two studies are considered and presented with the objective of contributing to an overall understanding of migrant farmworkers as a workforce moving across national boundaries and affected by the work environments and health stressors both shared and unique to each context. We propose a binational approach to comprehensively address the health problems and socioeconomic challenges faced by migrant and seasonal farmworkers. In this paper we present the results of two distinct but complementary studies of farmworker health on the Arizona-Sonora border.  Studies have found that farmworkers have high levels of chronic diseases such as diabetes and respiratory problems, are at risk for infectious diseases, and experience among the highest incidences of work-related injuries of any profession . On the pulation . In bothpulation . In Mexipulation ,10.jornaleros agrícolas, most of whom live elsewhere in Mexico and migrate to the country’s northern states for the agricultural season, had shifted considerably from the time of a previous survey in 1998 [versus the US.A 2003 survey in the state of Sonora found that the demographic characteristics and transitory patterns of  in 1998 . Along tOn the other hand, temporary migrant workers in Mexico are frequently the same population that migrates to the US. Consequently, a binational approach is needed in order to comprehensively address the health problems and socioeconomic challenges faced by migrant and seasonal farmworkers. Improved policies can establish farmworker health and safety protections as well as address the social and political factors affecting their lives.In this paper we present the results of two distinct but complementary studies of farmworker health on the Arizona-Sonora border. The Arizona-Sonora border is an important region for the agricultural industry due to the climatic conditions that allow for a vital winter growing season. Arizona’s four border counties, Yuma, Santa Cruz, Pima and Cochise, share a southern border some 350 miles long with the Mexican state of Sonora. Yuma County is known as the lettuce capital of the nation, and lettuce is Arizona’s leading cash crop. Other major crops include broccoli, cauliflower, citrus and melons. Yuma County has the largest number of farmworkers in the state, and it is estimated that Yuma employs about half of the farmworker population. Sonora is also the home to large scale production of fruits and vegetables that are produced for export to the United States and Europe. Findings from these two studies are considered with the objective of contributing to overall understanding of migrant farmworkers as a workforce moving across national boundaries and affected by the work environments and health stressors both shared and unique to each context. This comprehensive picture will allow us to create a profile of migrant farmworkers in the US-Mexico border region and provide recommendations for binational programs, practices, and policies that can greatly improve the health and wellbeing of this marginalized and underserved population.This US based study was a cross-sectional, population based survey conducted from August 2006 to February 2007 using a randomized proportionately representative household sample of farmworkers in the three communities of Somerton, Gadsden, and San Luis located along the US Mexico border in southern Yuma County, Arizona. The study was implemented by a multidisciplinary research team from the University of Arizona in partnership with a local farmworker agency, Campesinos Sin Fronteras. Funding was provided by the National Institute of Occupational Health and Safety. Households were identified using community maps and randomly selected census blocks. Standardized Spanish instruments were developed collaboratively based on reliable and validated surveys used by the California Hired Farmworker Health Survey in the California Agricultural Workers Health Survey (CAWHS)  that addThe survey was conducted door-to-door. Individuals were identified as farmworkers prior to being asked to participate in the study. Interviewers articulated the purpose of their visit, stated they were conducting an anonymous survey of farmworkers in the Yuma area and asked if someone in the household was over 21 years of age and working or had worked in the fields during the past year. If someone in the household met the criteria, they were invited to participate in the interview. If more than one adult in the household met the eligibility criteria, the interviewer would list in descending order of age, each man on one list, and each woman on another. Beginning with males, the interviewer would choose the one with the birth date closest to the interview date. If there were no males present in the household, then the woman with the birth date closest to the interview date would be invited to participate. Campesinos Sin Fronteras (CSF), a key collaborator and community-based organization focused on farmworker health issues in Yuma County, Arizona, was subcontracted by the University of Arizona (UA) to hire and supervise interviewers and provide oversight of the data collection process. To describe and compare farmworker populations in a border context and from a binational perspective data analysis consisted primarily of frequency distribution. Preliminary analysis of the survey (presented below) resulted in the need for more in-depth understanding of how respondents defined stress. Group interviews were subsequently conducted to further investigate significant themes, particularly regarding stress in the context of border residence as a farmworker or farmworker family member. Four group interviews were held with farmworkers recruited by Campesinos Sin Fronteras. The first consisted of farmworker men of over 40 years of age, the second of farmworker women over 40, the third of farmworker men and women between 18 and 30 years of age, and the final group consisted of male and female members of farmworker families who were not farmworkers themselves. The interviews were conducted in Spanish and lasted approximately 90 minutes. Demographics: Campesinos collected 298 household surveys and obtained an overall response rate of 92.7%, reflecting, we believe, the level of trust that Campesinos staff have established in the farmworker community. Similar to farmworker demographics, more men than women were interviewed (see vs. 7.1%), slightly younger, and were slightly more educated (67.1% of men had less than 6 years of school versus 76.3% of women). However, male and female farmworkers were similar in terms of place of birth and immigration status. Approximately half both male (55.2%) and female (51.7%) respondents had health insurance and this was most likely to be from the US.ewed see  and 78% ewed see . In the Health: When asked to rate their health status  cited the need to speak better English as a significant stressor and 41% experienced stress related to traveling far from their families to earn a living. Over 40% experienced stress associated with obtaining health services for their families, and many worried about supporting themselves and their families in the long term. Together with economic worries, farmworkers reported stress tied to a climate of fear or oppression in their border community. Stressors also included difficulty in getting ahead in the US due to their race, encounters with police and border patrol officials, the construction of the border wall, and the unjust treatment of others of their same racial and ethnic background. Focus group findings expanded on survey results with respect to stress. Along with stress related to lack of English skills and family separation, many also described stress caused by abusive or discriminatory interactions with officials from Customs and Border Protection and Border Patrol. Younger focus group participants in particular reported incidents of abuse. Moreover, participants reported work-related stress, including abuse from foremen and supervisors, as well as stress associated with agricultural work itself. Farmworkers in the focus group expressed a need for better working conditions, including higher salaries, health insurance and related benefits, opportunities to develop their skills, and prospects for improving English proficiency.Although the two studies are mainly descriptive, the mixed methods approach strengthened our discussion. Enrollment of workers in study 2 was voluntary and in accordance with the international Review Board policies for research with human subjects, the research team observed the non-discriminatory and voluntary participation policies. Sampling these migrant populations is challenging given they are constantly migrating between regions and farms. Moreover, they live and work in private enterprises whose owners are often reluctant to participate in studies investigating the living conditions of their workers. Accounting for these sampling conditions we can assume that there must be a sampling bias that is inherent to a very mobile population.promotores) who had been farmworkers themselves and knew the community quite well, resulting in a high response rate. However, the climate of fear due to the militarization of the border may have contributed to workers focusing more on those issues as stressors rather than some of the occupational stressors. Additionally border farmworker communities have unique issues related to being situated in a binational region and thus some of the findings may not be generalizable to farmworker communities in other areas of the country. Enrollment of workers in study one was voluntary in accordance with IRB policies for research with human subjects. Interviewers were local community health workers . The second study of migrant farmworkers in northern Mexico has provided an important opportunity for understanding some of the demographic and health characteristics of this population. A cross-border interdisciplinary research team surveyed 233 workers in agricultural labor camps located in the state of Sonora, and conducted 17 group and key informant interviews creating a demographic and health profile of the migrant population. The team included two sociologists, a physician and public health researcher, two nutritionists, an agronomist, a communication specialist and two public health professionals, from three different academic institutions in the US and Mexico . El Colegio de Sonora, CIAD, and UA research staff are all trained interviewers who have worked collaboratively on a number of other studies in the past. All interviewers/researchers were required to pass the Rochester Exam and provided training on data collection, confidentiality, and privacy issues. This training included an overview and point by point review of ethical interviewing practices, the anonymous nature of the survey, non-disclosure of respondents’ identities, addresses or any other identifiers under any circumstances, and the confidentiality of all interview content. Role plays were utilized in the training when appropriate. The study included a convenience sample collected on farms in Sonora between April and November of 2007. Funding was provided by the binational jornalero or jornalera who was living on the farm to ask for permission to be interviewed. Interviews were conducted on a total of 17 different days between April and November of 2007, for a total of 233 interviews. The interview questions were derived from instruments developed in the United States including the National Agricultural Workers Survey, the California Agricultural Workers Health Study [Agribusiness in Sonora consists of private businesses that require the owner’s permission to speak to workers who live on the farm premises. Three farm owners provided permission to visit their installations and talk to workers. A team of nine interviewers contacted each th Study , and theth Study  and fromjornaleros per group and eight key informant interviews with farm owners and farm managers. A guide was used to conduct group discussions. The discussions lasted 52 minutes on average. The discussions were audio-taped. Two observers took additional discussion notes, as well as non-verbal information considered of importance. Furthermore, in order to document the impact of living conditions within the farm, the study collected 64 dietary interviews  of adult men and women and nine menu registries from two of the farms’ dining halls. Based on the Dietary Guidelines for Americans (15) we categorized food consumption by type and nutritional content, in order to have a qualitative examination of diet adequacy.Descriptive statistics were used to analyze data from individual interviews. Qualitative analysis of group interviews was performed with N Vivo qualitative software 9.0 [In addition, a trained facilitator conducted nine group interviews, three per farm, including between two and five mericans  we categware 9.0 . A dietaware 9.0 ,17 and Cware 9.0  on regioDemographics: jornaleros in Sonora. The majority of the farmworkers (71.6%) were under the age of 35. Most participants were male (60.5%) and of low income. Fifty three percent (53.2%) percent had a sixth grade education or less, twenty seven percent (27.5%) completed secondary school (middle school) and almost five percent (4.7%) reported some high school or college level education. Farmworkers in Sonora reported their birth of origin from several states within Mexico. Most were from the poorest states such as Chiapas, Veracruz, Puebla and Guerrero, according to the human development index (HDI)  in theseenganchador, intermediario) and transported to farms in Sonora (northern Mexico) by buses paid in several ways: by intermediary, by the farm owner or in some cases by the Secretaría del Trabajo (Department of Labor). The majority of the samples (51.9%) were pendular stream migrants who go back and forth between their state of origin and Sonora with 25% of the sample moving from crop to crop in various states beyond Sonora and the state of origin. Twenty percent (20%) of the sample was settled out migrants who now live year round in Sonora.In Mexico, migrant farmworkers are hired in their communities (in southern Mexico) by an intermediary (The study focused on migrant farmworkers who were working in grape (69.1%) and vegetable (30.1%) farms in Sonora between April and November of 2007. Health: As seen in The Sonora study also examined a number of environmental determinants that impact health in this population of farmworkers and their families. Our data revealed that overcrowded living conditions were a serious health-related issues, which can be related to infectious diseases within this population. For those living in family housing , roughly 5 to 11 individuals were found sharing sleeping quarters in one room that measured 9 square feet. In addition, individual farmworkers sleeping in large overcrowded barrack-style structures increased their likelihood of transmissible diseases. During the study period, we found between 30 to 60 individuals per living quarter. Each room was fitted with three tiers of small cement beds stacked one above the other.While the environmental conditions proved inadequate, the nutritional status of farmworkers is just as inauspicious . Mostly comedores) where meals were prepared on site for farmworkers. Thirty percent (30%) of farmworkers (N = 153) reported that these meals were insufficient in satisfying their hunger or caused illness due to food intolerance or spoiled food. Diets consisted mainly of a combination of wheat (20%) and corn tortillas (80%), fried eggs, rice, chicken soup, tomatoes, cut meats, carbonated and sugary beverages, and coffee. In some cases, when the work is intense (as during the harvest seasons) energy intake is inadequate considering the high caloric expenditure characteristic of agricultural labor. This may be a risk to health among workers performing intensive activities such as the picking grapes. The quality of their diets is deficient as well. Sixty-four percent of total energy comes from simple (mainly sugared beverages and chips) and complex  carbohydrates, 13% from protein and 22% from fat. Although this appears to abide by internationally recommended standards for carbohydrates and fat, protein intake is low. On the other hand, diets are also low in vitamins A, C, and E and calcium. Tortillas made of corn meal are enriched with iron, zinc and folic acid, which allows for adequate intake of these micronutrients. It is important to note, however, the majority of protein and iron these families consume comes from vegetable sources, which compromises bioavailability and quality. In our study we learned that growers managed dining halls (venimos a sufrir) to describe their daily lives. At the same time they spoke of the necessity to seek out this work as in their home regions there were no jobs or forms of employment. In terms of their living conditions they spoke of overcrowding, high costs of food and drinks, monotonous diets and difficulty adapting to menus from a different region of the country. In group interviews the workers reported very deficient working conditions and on repeated occasions utilized the expression “we have come to suffer” , work-related stress can be caused or exacerbated by long hours and shift work, a poor social environment, lack of opportunity for growth, and unpleasant or dangerous physical conditions . All of Racial and ethnic discrimination, working and living conditions in Arizona, working, living conditions and perceptions of abusive treatment by employers in Sonora were documented in the focus group findings as a major sources of stress. This has larger repercussions for their overall health status. Studies have found that racial/ethnic discrimination is commonly linked to poorer mental health status, and can be associated with deteriorated physical health as well . In somejornaleros agrícolas and migrant farmworker populations, and the parallel issues they face, speak to a need for a binational response that includes increased social responsibility and attention to social factors and labor conditions as the following proposes:It is clear that the combination of the stress in the daily working and living environment, low educational levels, high poverty levels, and the lack of access to preventive and routine health care are issues that are faced by both populations. Poor diet is also an issue facing this population. At the social and political levels, a combination of supportive policies and social change need to take place in order to combat all of these factors and their ill effects on the population. The economic hardship driving the poor in Mexico to migrate north for work is the same that motivates them to cross the border. Extremely low wages and poor working conditions in Mexico increase farmworkers’ tolerance of conditions in the US, which are poor by national standards but considerably better than those in Mexico. The similarities of (1) Binational Agricultural Labor Standards: The institutionalization of agricultural labor standards on both sides of the border is a first step toward improving farmworkers’ lives. Like industrial laborers, farmworkers should be able to benefit from standardized, livable wages, safe working conditions, health care, and other benefits. Accessible health care alone would serve to alleviate many other life challenges faced by the population, including stress, poverty, and unemployment. A model of social responsibility in agribusiness can facilitate these changes, but it must be embraced by business leaders. Those who have embraced the process in Mexico or the US can serve as model for others, ultimately increasing productivity thereby demonstrating the value of the approach. A binational agreement or an accord between border states would be a key element to reform working conditions.(2) Moving toward a model of social responsibility: Recommendations emerging from the Sonora project include implementation of a model of corporate social responsibility with agricultural companies, in order to institutionalize better working conditions and benefits for farmworkers. New organizational efforts in the Yuma area are also looking to build partnerships with agribusiness and develop “codes of conduct” to be mutually agreed upon by workers and employers. Working conditions and health issues are only a few of the environmental stressors for farmworkers in the US and Mexico, but the potential for implementing positive change within agribusiness holds promise for improving farmworkers’ health and development.(3) Creating Binational Networks: Educational, health and social service agencies are working to assist migrant farmworkers on both sides of the border, but there is little communication or collaboration between them. Since migrant farmworker populations in the US and Mexico have similar demographic profiles and face parallel challenges, there is a benefit to be had in cross-border partnerships. The establishment of a binational network for farmworker health and development would allow agencies to share information, strategies, materials, and resources to enrich their services and advocate more effectively for their clients.Although the two studies are mainly descriptive, the mixed methods approach strengthened our discussion. Enrollment of workers in study 2 was voluntary and in accordance with the international Review Board policies for research with human subjects, the research team observed the non-discriminatory and voluntary participation policies. Sampling these migrant populations is challenging given they are constantly migrating between regions and farms. Moreover, they live and work in private enterprises whose owners are often reluctant to participate in studies investigating the living conditions of their workers. Accounting for these sampling conditions we can assume that there must be a sampling bias that is inherent to a very mobile population.jornaleros are aware of being discriminated during their visits to health care facilities. It is essential to recognize and analyze the complex needs and special conditions of farmworkers in order to develop programs and policies that afford them dignity and policies that raise their standard of living, which comes with earning a livable wage.Migrant farmworkers in the US and Mexico live outside of mainstream society. In the US, the legal status of the population tends to be a mix of visa holders, permanent legal residents, the undocumented, and some US citizens. In northern Mexico they are increasingly an indigenous population coming from southern and central Mexico. In both cases they are marginalized from benefits and services available to most people in both countries. The health issues faced by farmworkers, such as diabetes, mirror those of the poor nationally, but farmworkers are unable to access health services they may qualify for due to cultural and language barriers, rural status, and transitory lifestyles. In the US there is the added element of anti-immigrant sentiment and hostilities along the border affecting the mental and physical health of the population, a phenomenon that is only beginning to be understood. The latest legislation involves the state of Arizona. The Arizona legislature recently passed SB 1070, which gained national attention. This legislation requires law enforcement agencies and officials of the state of Arizona to assist in enforcing federal immigration laws. It also grants county attorneys the power to subpoena when investigating employers that hire undocumented workers among other requirements . In Sono


Respiratory diseases are the major disease crisis in small ruminants. A number of pathogenic microorganisms have been implicated in the development of respiratory disease but the importance of environmental factors in the initiation and progress of disease can never be overemphasized. They irritate the respiratory tree producing stress in the microenvironment causing a decline in the immune status of the small ruminants and thereby assisting bacterial, viral, and parasitic infections to break down the tissue defense barriers. Environmental pollutants cause acute or chronic reactions as they deposit on the alveolar surface which are characterized by inflammation or fibrosis and the formation of transitory or persistent tissue manifestation. Some of the effects of exposures may be immediate, whereas others may not be evident for many decades. Although the disease development can be portrayed as three sets of two-way communications , the interactions are highly variable. Moreover, the environmental scenario is never static; new compounds are introduced daily making a precise evaluation of the disease burden almost impossible. The present review presents a detailed overview of these interactions and the ultimate effect on the respiratory health of sheep and goat. Indian livestock sector has emerged as one of the key components of national as well as agricultural growth with an annual contribution of 3.93%  of national GDP and 22.14% share in the agricultural GDP. Today, India ranks first with respect to buffalo, second in cattle and goats, and third in sheep population in comparison to the world livestock population  for a reBroadly, the term “environmental pollution” refers to presence of any agent or a chemical in the environment of an individual which is potentially hazardous to either the environmental or individual's health. As such, environmental pollutants may take many forms: chemicals, organisms, and biological materials, as well as energy in its various forms . The actual number of potential pollutants is therefore incalculable. Less than 1% of these pollutants have been subjected to a detailed appraisal in terms of their toxicity and health risks . FurtherRespiratory diseases are the major disease crisis in small ruminants , 10. A nThe respiratory tract of an adult goat comes into contact with approximately 7-8 liters of air per minute, that is, 11,000 liters of air in a day. Thus, the quality of inhaled air has major implications on the respiratory health of the animals. The respiratory system of sheep and goats is quite adaptable against a plethora of air contaminants , while cThe production of disease in an animal is determined by three basic factors: the host, the pathogen, and the environment . The relO. canadensis) populations has been associated with highest lungworm parasite loads [ Muellerius spp. infections also typically do not produce clinical disease in domestic sheep [The severity of onset of clinical disease in the host is decided chiefly by the pathogenicity of the prevalent population of the pathogen. The term pathogenicity includes both virulence and aggressiveness. The adaptation mechanisms of the pathogen to the altered environmental factors play an important role in determining its survival in the host and the environment as a whole. The reduction in heterozygosity in disease resistance genes of bighorn sheep  translocated to Hawaiian Islands for sport hunting provided a unique opportunity to understand how disease processes may be affected by environmental conditions [Environmental variables have conventionally been accepted as the major determinants for disease development . Even thnditions .The aerographic conditions commonly include the state of atmospheric air in terms of temperature, wind velocity, clouds, precipitation, and volcanic eruptions. The prevailing climatic conditions have a major impact on the survival of the pathogens . An alte P. multocida often exists as a commensal in the upper respiratory tracts of majority of livestock species and has also been identified as the most frequently isolated bacteria from pneumonic lung [High humidity increases the risk of heat stress at any air temperature. The heat index (temperature + humidity) is considered as a more accurate measure of heat stress (hyperthermia) by veterinarians than temperature alone . Heat stnic lung  but the Moisture also influences outbreak of respiratory diseases caused by microorganisms like bacteria and fungi and nematodes . The infIn addition, the dissemination and resulting concentration of the pollutant may vary significantly depending on the prevailing  conditions at that time. Patterns of atmospheric dispersion, for example, change not only in relation to wind speed and direction but also temperature inversion effect and atmospheric stability . StatistAnimal housing is also an important consideration in evaluating the impact of outdoor aerographic conditions on the health of the animals. Animals living indoors are less likely to be affected by rain and thunderstorms but poor ventilation and unhygienic barns are usually associated with severe outbreaks of respiratory diseases. The grazing goats have been reported to show about 2-3-fold higher morbidity as compared to the stall-fed animals . AmongstClimate is the statistical information that expresses the variation of weather at a given place for a specified interval of time. Climate change is likely to directly affect the physiological profile of animal by altering the homeostasis and other thermoregulatory functions and hence its health and productivity. Climate may also influence health of animals indirectly by disturbing the nutritional supply thus, decreasing resistance to diseases and pests. Impact of Climate Change. Inter-Governmental Panel on Climate Change has projected that global earth temperature will increase by 1.8–4.0°C by the end of this century [ E. coli-borne septicemia with major involvement of upper respiratory tract and lungs [ century . This in century . Further century . Rise in century . In the  century . Furthernd lungs .Atmospheric pollution remains a major health hazard to all the living species throughout the world and shares about 8-9% of the total disease burden , but theExposures to pollutants may occur through a number of pathways and exposure processes. Inhalation of environmental pollutants is generally over a considerable period of time and thus usually elicits health issues on chronic basis, but occasional inhalation of solid particles deposited from industrial exhaust on pasture land may directly cause an acute response. The increased incidence of pasture originated disease can be attributed to their short stature due to which they breathe closer to the ground as compared to cattle and hence are more likely to inhale the solid particulates deposited on the pasture. The lesions produced in small ruminants such as sheep and goat due to air pollution are chiefly inflammatory in nature as was observed in 1952 smog disaster  that increased respiratory tract hyperresponsiveness and ultimately resulted in respiratory distress (and right-sided heart failure) of cattle that were housed in the city  owing toThe relationship between pollution and health is both a multifaceted and conditional process. For pollutants to have an adverse effect on health, susceptible individuals must receive a minimal dose of the pollutant, or its metabolite, over a period sufficient to trigger detectable symptoms. Pollutants rarely occur in isolation; typically they exist in combination . ExposurIrrespective of the origin, the ultimate health hazard imposed by all pollutants depends upon their persistence, mobility, biotransformation, and their toxicity profile. The problems associated with the release of persistent pollutants like chlorinated pesticide, DDT (Dichlorodiphenyltrichloroethane), into the environment were highlighted with recognition of the global extent of contamination and a wide-range of environmental and health effects . The sigμ) are more likely to reach the lung alveoli, but airborne particles up to 5 microns in size may also do so. In general, larger particles (10 μ or greater) are trapped and removed by the mucus and cilia of the upper respiratory tract. Inorganic mercury is persistent but less toxic and less readily bioavailable than methyl mercury, which gets converted naturally through chemical reactions by microorganisms [Mere persistent nature of a pollutant does not endorse the health risk; its presence in a form that is accessible to the lungs is also important to produce respiratory disease. The development of environmentally induced lung disease is a function of the intensity and duration of the exposure as well as the inherent toxicity of the inhaled substance and susceptibility of the host. The physical status of the inhaled substance , the particle size, and other physicochemical characteristics (like solubility) principally determine the initial location of disease development. Smaller particles , M. mycoides subsp. capri , M. bovis [ M. ovipneumoniae [ M. ovipneumoniae is one of the most important mycoplasmas involved in the respiratory diseases of sheep. Combined effects of ammonia and bacterial endotoxins predispose the animals to respiratory infections with viruses and bacteria, both primary pathogenic as well as opportunistic species. Although food producing animals appear to be capable of maintaining a high level of efficient growth in spite of marked degrees of respiratory disease [Bacterial infections in a sheep and goat farm are a common clinical and subclinical finding –60. Somella spp. , Staphyleumoniae , ArcanobM. bovis , and M. eumoniae . Out of  disease , at a ce disease , 66.Respiratory diseases in sheep and goats are generally an outcome from physiological stress with viral and bacterial infections and adverse weather exposure . Predisp in vivo redox homeostasis. Stress is one of the basic requirements for disease development  and tumor necrosis factor-alpha  have been proven to mediate the development of numerous inflammatory lung diseases . A numbephylaxis . Zinc suphylaxis . Antioxiphylaxis . VitaminAlthough the disease development can be described as three sets of two-way communications , this is a generalization. All three groups of factors interact in a highly variable manner in any real life scenario, often in nonlinear ways that are difficult to compute and forecast.Estimating the contribution of environmental pollution to the burden of disease is far from simple. The global atmospheric pollution scenario is too difficult to classify and define completely. Moreover, it is never static; new pollutants are being introduced to the air every day and too little is known about their interactions with respiratory health, or about their levels of exposure, to make reliable toxicity appraisal. These difficulties are more pronounced in developed countries, where disease surveillance, reporting of mortality, environmental monitoring, and population data systems are all relatively well approved. Still precise evaluation of the disease burden is yet worth the endeavour.The animal biodiversity available in our country is a virtual goldmine of germplasm. Some of the indigenous breed of livestock like Jamunapari goat have unique characteristics of adaptability to adverse agroclimatic conditions, better disease tolerance, feed conversion efficiency, and zero managemental requirements. Therefore, maintain a livestock population that is sustainable in the present everday changing climatic scenario is a challenging task, which would require a change in breeding policy, perpetuating disease resistant and climate adaptable traits, capacity building, and regional and global cooperation.


Although the Internet is a promising medium to offer lifestyle interventions to large amounts of people at relatively low costs and effort, actual exposure rates of these interventions fail to meet the high expectations. Since public health impact of interventions is determined by intervention efficacy and level of exposure to the intervention, it is imperative to put effort in optimal dissemination. The present project attempts to optimize the dissemination process of a new online computer tailored generic lifestyle program by carefully studying the adoption process and developing a strategy to achieve sustained use of the program.A prospective study will be conducted to yield relevant information concerning the adoption process by studying the level of adoption of the program, determinants involved in adoption and characteristics of adopters and non-adopters as well as satisfied and unsatisfied users. Furthermore, a randomized control trial will be conducted to the test the effectiveness of a proactive strategy using periodic e-mail prompts in optimizing sustained use of the new program.Closely mapping the adoption process will gain insight in characteristics of adopters and non-adopters and satisfied and unsatisfied users. This insight can be used to further optimize the program by making it more suitable for a wider range of users, or to develop adjusted interventions to attract subgroups of users that are not reached or satisfied with the initial intervention. Furthermore, by studying the effect of a proactive strategy using period prompts compared to a reactive strategy to stimulate sustained use of the intervention and, possibly, behaviour change, specific recommendations on the use and the application of prompts in online lifestyle interventions can be developed.NTR1786 and Medical Ethics Committee of Maastricht University and the University Hospital Maastricht (NL2723506809/MEC0903016).Dutch Trial Register  Due to its high accessibility and its potential to reach large numbers of people, the Internet is considered to be a promising medium in the field of health promotion for offering tailored and targeted behaviour change programs to the general public -5. Over Since public health impact of interventions is determined by their efficacy and exposure in the target group ,25, it iThe current project aims at optimizing exposure rates of a combination of several effective online CT programs, targeting physical activity, fruit and vegetable consumption, smoking and alcohol consumption, offered through the Internet. This combined CT program will be integrated in the Dutch Adult Health Monitor, a monitoring tool used by all Regional Public Health Service (RPHS) in the Netherlands in order to assess different aspects of general health and health related topics at fixed points in time. This integration will result in an online program that respondents of the Dutch Adult Health Monitor can turn to in order to obtain detailed and personalized information regarding their current health behaviour status, as well as personalized advice on how to improve their health by focusing on the key health behaviours.Several theories underline the importance of different processes to foster effective diffusion of interventions ,32. ThesCurrently computer tailored interventions are offered reactively to the public, implying a passive approach in which users themselves must undertake action in order to benefit from the intervention . Prior rpro-active approach using periodic e-mail prompts in order to obtain sustained use of the intervention over time will be studied in a randomized control trial.In order to optimally disseminate the program, the present research project will thoroughly investigate adoption of an online CT lifestyle program and development of strategies to achieve sustained use. First, studying the adoption process will yield results on the level of adoption, determinants involved in adoption and characteristics of adopters and non-adopters as well as satisfied and unsatisfied users. A strategy aimed at increased and sustained level of use will be designed and tested. On that account the efficacy of a The current project emphasizes the processes of first use (adoption) and re-use of a combined computer tailored online lifestyle program, by examining each process in a single study. First, a general description of the CT program will be provided, before proceeding to the detailed description of the separate studies.NTR1768).The current project is approved by the Medical Ethics Committee of Maastricht University and the University Hospital Maastricht (NL27235.068.09/MEC 09-03-016), and is registered with the Dutch Trial Register  [fruit and vegetable intake, measured by the Short Questionnaire for Fruit and Vegetable Intake [alcohol consumption, measured by the Dutch Quantity-Frequency-Variability Questionnaire (QFV) [smoking, measured by the abbreviated version of the Fagerström Test for Nicotine Dependence [The Adult Health Monitor takes place with an interval of four years and serves as a monitoring tool used by the RPHS's to assess the overall level of health in the Dutch population by approaching a representative sample of the population to fill out a questionnaire assessing different aspects of general health  and health related topics  . Physica(SQUASH) , fruit ae Intake ,42, alcore (QFV)  and smokpendence . ResultsIntegrating the new CT program into the Adult Health Monitor may have several benefits. Firstly, it can enable the RPHS's to optimize their public health education task; besides solely monitoring health behaviour, the RPHS's now have an opportunity to provide people with personalized advice on how to change their health behaviours. Furthermore, it may provide the random sample of adults included in the Adult Health Monitor an incentive for their participation and might serve as a cue to action for them to positively change their health behaviour. Since the current CT program is embedded in the Adult Health Monitor of the Provinces of Limburg, Brabant and Zeeland, with an approximate total reach of 100.000 inhabitants, this integration also provides an important access point for reaching a considerably large segment of the Dutch population with a lifestyle intervention.The CT program uses a step-by-step approach to guide people towards behaviour change. After online completion of the Adult Health Monitor people are informed in detail on the embedded program and the accompanied studies. People that indicate to be interested in the program are subsequently linked to the program. During their first visit demographic data  and personal data concerning the target health behaviours, acquired through the Adult Health Monitor questionnaire, are transferred to the CT program and used to inform people on the current status of their health behaviours by comparing these to Dutch public health guidelines  or two (men) glasses of alcohol a day and non-smoking). In case of discrepancies, people are alerted and provided assistance in changing their health behaviour(s) with help of CT advices available per behaviour.Changing health behaviours with help of computer tailoring is the main component of the program. A CT module is available per health behaviour and within each module people have the opportunity to obtain personalized advices regarding the opted health behaviour. All health behavioural advices are adapted to individuals' characteristics by considering demographic, behavioural and social-cognitive variables ,45,46. SMessage content and algorithms of the CT advices are based on prior theory and evidence based CT interventions on physical activity, fruit and vegetable intake, alcohol consumption and smoking cessation ,37,38,48The main goal of the first study is to assess the level of first time use of the new CT program, frequency of use, level of satisfaction with the new CT program by participants of the Adult Health Monitor 2009 and determinants of adoption and use. Furthermore, characteristics of users and non-users and satisfied and unsatisfied users will be investigated.This is a prospective study, employing a longitudinal design. At baseline participants of the Adult Health Monitor interested in the new CT program receive feedback concerning their current health behaviour. In case of a negative discrepancy between the status of their current health behaviours and public health guidelines set for these behaviours participants are stimulated to change these behaviours with help of the CT program. During a period of three months, use of the CT program is monitored anonymously resulting in a detailed overview of number of first visits, revisits, and the specific health behaviours selected.The research sample consists of Dutch adults participating in the Adult Health Monitor 2009 of the Dutch Provinces of Limburg, Brabant and Zeeland. The RPHS's will invite a representative sample of inhabitants of the provinces North-Brabant, Zeeland and Limburg (+/- 100.000) by mail to participate in the Monitor. Participants will be offered the opportunity to fill out a written questionnaire, which is included, or to complete an online version of the Monitor questionnaire. Electronic completion will be highly encouraged since the new CT program is an online program only accessible for respondents participating via the Internet. Based on previous experiences with this Monitor it is expected that a response rate of approximately 33% will be reached, indicating that about 33.000 respondents will fill out the Adult Health Monitor.online version are introduced to the new embedded program, which is free of charge and consists of an opportunity to receive CT feedback about their health behaviour. Participants indicating to be interested in the new program will be asked to leave their e-mail address and receive an e-mail including an invitation to log in to the CT program with a personal login code and password approximately three weeks after completion of the Monitor. After logging on to the program participants receive detailed information on the goal and the content of both studies described in this protocol. After receiving this information, participants are asked to fill out an online informed consent form. Only those participants that consent to participation are directed to the new service. Subsequently, data on demographics and the five health behaviours obtained through the Monitor are transported to the new program, resulting in a personal overview in which an individual's current health behaviour status is compared to the guidelines set for these health behaviours. Within the program, five modules generating CT health advice are available to assist participants in changing their current health behaviour status when needed. Once respondents decide to leave the CT program after their first visit, they will be asked to fill out an additional questionnaire to assess their satisfaction with the program and their intention to revisit the program again in the near future  and one item assessing overall satisfaction .Intention to re-use the CT program is assessed by using a 10 point intention scale ('I intend to use this CT program again in the near future').To measure the adoption level of the new CT program focus will be on level of first use, demographic and behavioural characteristics of users and non-users, satisfaction with the program, characteristics of satisfied and unsatisfied users, intention to re-visit the program and frequency of re-visits. In order to measure level of first use of the program, two dichotomous variables will be created; one indicating whether participants initiate a behaviour change module and one indicating whether participants finish the module. Initiating a module is labelled as "yes" when people fill out the first question of this module, which is the question concerning intention to change the specific health behaviour. Completion of a module is labelled as "yes" when people also fill out the final question of the module. Re-visiting of the program will be assessed monitoring whether participants log in to the program within a three month period after baseline (0 = yes/1 = no). Re-visits to the program will be measured by comparing the dates of log-in to the baseline date.First, general descriptive statistics will be used to describe personal characteristics of the participants, as well as main findings concerning current health behaviour status, adherence to the public health guidelines and socio-cognitive characteristics. Second, logistic regression analyses will be conducted with initiation of a module, completion of a module and revisiting of the program as dependent variables. Demographics, such as gender, height, weight, marital status, religious background, ethnicity, educational level, current work status, income, health behaviour status and cognitions (measured at baseline) are included in the model as predictors.The aim of this study is to test the effect of using a proactive approach (i.e. periodic e-mail prompting) on revisiting of the program compared to a reactive approach. Furthermore, the efficacy of these approaches with regard to behaviour change will be studied.The second study consists of a randomized control trial (RCT) including one experimental group. A design with a baseline measurement and three follow-up measurements  measuring health behaviour status, intention to change, cognitive variables and planning abilities, will be used to compare the experimental condition (use of a proactive technique) to a control condition (use of a reactive approach).The research sample consists of individuals that participate in the Dutch Adult Health Monitor and that decide to pay a first visit to the new CT program. After logging in to the program at baseline and consenting to participation by filling out an online informed consent form, participants are randomly assigned to one of the two conditions. People in the experimental condition are reminded proactively via e-mail every three months for a period of 18 months to visit the CT program in order to obtain iterative feedback concerning their health behaviour status and additional CT advice, whereas people in the control condition do not receive any additional prompts and are only encouraged to re-visit the program in the future at baseline. All participants will be invited by e-mail for the follow-up measurements at 6, 12 and 18 months .Interested participants are directed through the Adult Health Monitor to the new program, where they can log in to the program with a personal username and password. After signing in to the program, participants will be randomly allocated to either the control condition or the experimental condition. Randomization will occur at the respondent level by means of a computer software randomization device. Blinding of participants is not possible, since participants will take notice of the fact that they receive additional e-mail prompts or not.The primary outcome measures are re-visits to the program and level of behaviour change. Program revisits are objectively monitored for a total period of eighteen months. Recordings will be done anonymously and will yield information about the number of times the program is visited, the duration of each visit (in minutes) and which specific behaviours are most frequently selected. Level of behavioural change is assessed by studying participants' adherence to public health guidelines set for these behaviours (0 = not complying with recommendations/1 = complying with recommendations).Secondary outcome measures include overall tobacco use (number of cigarettes/day), level of physical activity (minutes/day), and overall level of fruit (pieces/day), vegetables (grams/day) and alcohol consumption (glasses/day). Furthermore, socio-cognitive measures, such as intention, attitude, social influence, self efficacy, action and coping planning will be measured.With regard to re-visits to the program (first primary outcome measure), it is estimated that approximately 50% of the respondents of the no-prompting condition will visit the site more often than four times . It is estimated that in the prompting condition 70% of the respondents will visit the site more than four times. Power calculations reveal that in order to be able to detect this difference with a power of 80% (p = .05) at least 186 persons per condition are needed. Taking into account potential attrition, it is proposed to collect the data of 250 persons per cell.p-value of .05. It is estimated that, in order to detect this significant difference in quit rates, 219 smoking persons per cell are needed, resulting in a total of 438 smokers [The second primary outcome measure is the level of health behaviour change. The current program entails a total of five health behaviours. Therefore, with regard to the assessment of behaviour change (second outcome measure), estimations for finding effects will be based on smoking, since this behaviour results in the most conservative power calculations. Approximately 25% to 30% of the population smoke . Power e smokers . To be aFirst, general descriptive statistics will be used to describe personal characteristics of the participants, as well as findings concerning current health behaviour status, adherence to the public health guidelines and socio-cognitive characteristics. Second, logistic regression analyses will be conducted with re-visits to the program and level of behaviour change as dependent variables. Furthermore, linear regression analyses will be conducted with number of re-visits, duration of re-visits and number of behaviours selected as dependent variables. Demographics, such as gender, height, weight, marital status, religious background, ethnicity, educational level, current work status, and income, health behaviour status and cognitions (measured at baseline) will be included in the model as predictors of the dependent variables.Although the Internet is a promising medium to offer lifestyle interventions , it is nadoption of the intervention and development of a strategy to achieve sustained use of the intervention over time [Since optimal dissemination largely depends on the processes of actual ver time , each prver time . TherefoCT: Computer tailoring; RPHS: Regional Public Health Service; SQUASH: Short QUestionnaire to ASsess Health-enhancing physical activity; QFV: Quantity-Frequency-Variability questionnaire.The authors declare that they have no competing interests.FS significantly contributed to writing this paper, while LvO, DS, MvA, SK and HdV were involved in revising the manuscript. The project design was developed by HdV. All authors were involved in implementing the project. All authors have approved of the version to be published.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2458/11/480/prepub


The Hospital Elder Life Program (HELP) has been shown to be highly efficient and (cost-)effective in reducing delirium incidence in the USA. HELP provides multicomponent protocols targeted at specific risk factors for delirium and introduces a different view on care organization, with trained volunteers playing a pivotal role. The primary aim of this study is the quantification of the (cost-)effectiveness of HELP in the Dutch health care system. The second aim is to investigate the experiences of patients, families, professionals and trained volunteers participating in HELP.A multiple baseline approach  will be used to evaluate the (cost-) effectiveness of HELP in a cluster randomized controlled study. All patients aged 70 years and older who are at risk for delirium and are admitted to cardiology, internal medicine, geriatrics, orthopedics and surgery at two participating community hospitals will be included. These eight units are implementing the intervention in a successive order that will be determined at random. The incidence of delirium, the primary outcome, will be measured with the Confusion Assessment Method (CAM). Secondary outcomes include the duration and severity of delirium, quality of life, length of stay and the use of care services up to three months after hospital discharge. The experiences of patients, families, professionals and volunteers will be investigated using a qualitative design based on the grounded theory approach. Professionals and volunteers will be invited to participate in focus group interviews. Additionally, a random sample of ten patients and their families from each hospital unit will be interviewed at home after discharge.We hypothesize that HELP will reduce delirium incidence during hospital admission and decrease the duration and severity of delirium and length of hospital stays among these older patients, which will lead to reduced health care costs. The results of this study may fundamentally change our views on care organization for older patients at risk for delirium. The stepped-wedge design was chosen for ethical, practical and statistical reasons. The study results will be generalizable to the Dutch hospital care system, and the proven cost-effectiveness of HELP will encourage the spread and implementation of this program.NTR3842Netherlands Trial register:  In the next 30 years, the proportion of people 65 years and older is expected to increase to account for 25% of the general Dutch population, compared to 15% in 2008 [Delirium is characterized by an acute disruption of attention and cognition  and is tPatients with delirium are at an increased risk for complications and mortality during a hospital stay. Delirium can further result in adverse events after hospitalization, including lasting functional limitations, persistent cognitive decline, loss of quality of life for the patient and family, re-hospitalization and nursing home admission -8. UnforPreventing delirium is preferred over treating delirium, and attention should therefore focus on (multi-faceted) prevention interventions. Recently, a meta-analysis of five studies of 1,491 older patients concluded that the perioperative use of antipsychotics may reduce the overall risk of postoperative delirium among older people  and someRelatively little high quality research on delirium prevention (not including postoperative treatment) has been published , and an In this project, the primary aim is to investigate the (cost-)effectiveness of the Hospital Elder Life Program (HELP) in the Dutch hospital care system; this program has been shown to be effective in the USA for the prevention of delirium in older adults during hospital admission to both internal medicine and surgery departments. HELP has been shown to be effective in reducing the incidence, duration and severity of delirium  and decrAlthough HELP has been disseminated at a number of USA and internationally ,21, onlyA multiple baseline approach   will be Over a period of 18 months, eight hospital units of the Hospital Gelderse Vallei in Ede and the Diakonessenhuis in Utrecht and Zeist in the Netherlands will successively receive the intervention; new units will start every three months.To investigate the experiences of patients, families, professionals and trained volunteers involved with the HELP program, a qualitative design study based on the grounded theory approach ,25 will Eligible participants are patients ages 70 years and older who are at risk for delirium and are admitted to the cardiology, internal medicine, geriatrics, orthopedics and surgery units of the two hospitals. The Diakonessenhuis is situated in two locations , while the Hospital Gelderse Vallei is located in a more rural area.Eligible patients will be approached by the nurse on call for participation within 24-hours after hospital admission. Inclusion criteria are being 70 years and older, the absence of delirium at hospital admission and being considered at risk for delirium.To assess whether a patient is at risk for delirium, we use the three questions of the Hospital Safety Program launched in the Netherlands in 2009 that are part of obligatory hospital care. A review of literature was done before choosing these questions . The nurExclusion criteria include a life threatening situation, being in a palliative phase at admission, an expected hospital stay of 24 hours or less, being legally incapable of participating, unable to communicate verbally, or a second hospital admission during the study period. If the patients are transferred to a participating unit, they are treated as a newly admitted patient; if the patients are transferred from a participating unit to a nonparticipating unit, they are excluded from the study.The sample size calculation was based on the primary endpoint incidence of delirium, as diagnosed by the Confusion Assessment Method (CAM) . AccordiA total of 1648 patients ages 70 and older are hospitalized annually in the Diakonessenhuis. In the Hospital Gelderse Vallei, a total of 1393 patients aged 70 years and older are hospitalized annually. These hospitalizations result in 3,041 patients admitted per year, of whom at least two-thirds are expected to be at risk for delirium. This expectation is based on figures from hospitals that have already implemented the three question delirium risk assessment. This calculation should be sufficient for determining the total number of participants that are needed  for the proposed study.The Hospital Elder Life Program (HELP) is an innovative program for the prevention of delirium in hospitalized older people. The strengths of the program include the targeted nature of the interventions, early intervention focusing on prevention, well-trained staff dedicated to the program, standardized intervention protocols, tracking of adherence to all protocols, and built-in quality assurance procedures . The fouProtocols targeting risk factors1) The program provides standardized protocols targeted toward six important delirium risk factors. These factors were selected on the basis of evidence of their association with the risk of delirium and because they were amenable to intervention. These risk factors include cognitive impairment, sleep deprivation, immobility, visual impairment, hearing impairment, and dehydration.Elderly care nurse practitioner2) The Elderly Care Nurse Practitioner, who will be introduced as part of the program, plays a central role in HELP. The nurse practitioner will provide a baseline geriatric assessment upon admission and during the project, will develop and implement interventions in collaboration with the nursing staff and other disciplines and will include the patients in the process. This nurse will also provide educational programs and bedside teaching for nursing staff and will coordinate interdisciplinary rounds. The nurse practitioner will receive extensive training concerning assessment of the questionnaires and measurements and how to obtain informed consent. The nurse practitioner will work in close collaboration with a geriatrician.Trained volunteers3) Trained volunteers are a unique feature of HELP and are innovative in Dutch hospital care. The coordination of all volunteer activities in HELP will be conducted by a specially trained coordinator and the nurse practitioner. The trained volunteers play a crucial, central role in HELP by conducting the interventions directly at the bedside. The volunteers will stimulate patients to eat, drink and walk; read newspapers with the patients, and participate in (word) games and other activities with the patients. The volunteer training consists of classroom instruction that includes didactic training, small group demonstration, role playing and case discussions. Volunteers will communicate with each other, the nurse practitioner and the nurses during each volunteer shift. Volunteers will be additionally coached and trained quarterly with educational sessions and discussion groups.Patient-friendly4) HELP is unique in its approach of being patient-friendly by being directed at the wishes and needs of the older patients and in guaranteeing additional psychosocial support. Patients will receive personalized interventions that match their changing needs throughout the course of hospitalization. Enrolled patients will be regularly reassessed by the HELP staff, and nurses and supervised volunteers will administer interventions that are reassigned daily and tracked for adherence.All HELP protocols, training manuals and procedures are available for on-site registered hospital units wishing to start a HELP site . For thiThree months prior to the first hospital unit starting with HELP, all participating units will receive presentations on the content of the study and the measurements. The purpose of this period is to draw attention to the measurements that nursing should use to assess a patient’s risk for delirium. Baseline data will be collected during this time.As described, every three months, one hospital unit in both hospitals will start the intervention. The four hospital units in both hospitals are comparable. The units that admit the most older patients were chosen. The staff will be made aware of the study’s time schedule and will know when they are in the control or intervention period. Before the unit starts with the intervention, a team of HELP volunteers will be assembled and will receive a two day training program that was specially developed for HELP. The researcher and local project leader will work closely with the volunteer coordinator, the trainers and the head of the hospital unit. The researcher will give regular presentations for the nurses of the hospital unit and will keep the hospitals informed with regular newsletters and messages on the hospitals’ webpages. The doctors, physical therapists and other professionals in the hospital unit will be informed by the project leader.Each hospital has created a group of experts that gathers approximately every two months to discuss the HELP plans and its progress. This group can consist of the head and nurses of the participating hospital units, a doctor, the volunteer coordinator and the project leader.Figure The HELP study has been approved by the Medical Ethics Board of the University Medical Center of Utrecht. Both the Hospital Gelderse Vallei in Ede and Diakonessenhuis in Utrecht and Zeist have reviewed the study protocol. The board concluded that the study was feasible. Informed consent will be obtained, and patients can always decide not to participate. The study is registered in the Netherlands Trial Register (NTR3842).The Six-Item Cognitive Impairment Test (6-CIT) is a brief cognitive test that correlates well with the Mini-Mental State Examination (MMSE). The use of this test as a screening instrument for older people in hospital care has been studied and compared to the MMSE . The senThe 6-CIT will be administered by the nurse practitioner within 36 hours after admission, will be used to gather information on cognitive functioning, and can help inform the decision to consider a patient for participation.The incidence of delirium will be diagnosed with the Confusion Assessment Method (CAM) , whereasThe CAM, a 4-item diagnostic instrument, was designed as a screening tool for people who are at high risk of delirium  and is sThe CAM assesses the presence of four delirium features: acute onset and fluctuating course, inattention and distractibility, disorganized thinking and illogical or unclear ideas, and an alteration in consciousness. A review concluded that the CAM has become widely used, mainly because of its ease of use and accuracy ,37. The The DOS was developed to facilitate early recognition of delirium, based on nurses' observations during regular care; this scale uses DSM-IV criteria for delirium, a literature review, and clinical experiences . This meThe Delirium Rating Scale was developed in 1988 and revised in 1998 . This scHealth related quality of life  will be measured with the EQ-5D  at baselEach dimension comprises three levels . The EQ-5D may be used to calculate quality adjusted life years (QALYs).Test-retest reliability has been shown to be good, and the test is easy to use to measure both the presence of clinical symptoms and changes in these symptoms over time .The quality of care will be examined by means of focus groups. The quality of the care “process” experienced by the patients will be studied at each of the participating units during the period of data collection. Focus group meetings will be held with the multidisciplinary HELP-team. These focus groups will be led by a qualitative researcher with the assistance of the HELP-trained professionals and research-project members. The HELP program, care pathways, and the cooperation within the multidisciplinary team are topics that will be discussed by these focus groups. Next, qualitative interviews with the patients and their family members will be conducted. The objective of these interviews is to collect information on the experiences and opinions about the HELP program from both the patients and their next of kin.Furthermore, the HELP volunteers will participate in a so called focus group to evaluate their role and experiences; each unit will have one group that participate every month during the first half year and then every two months during the period of data collection.The primary effect parameter of the economic outcome evaluation will be the number of prevented cases of delirium. The costs of the HELP program will be calculated as well as the costs of care consumption of both patients who received HELP and patients who did not both during and after their hospital stay. After discharge, the patients will be contacted three times by telephone during a period of three months for assessment of their care consumption. During this telephone call, patients will be asked eight short questions addressing the following topics: possible hospital (re)admissions, nursing home or rehabilitation center admissions, home care, domestic help, informal care, visits from the general physician and psychological care. If the patients are not able to participate, a close family member will be asked for information on the care that the patients have received after discharge. Differences in total cost between the intervention and control groups will be compared.The aim of the main analysis is to compare the incidence, severity, and duration of delirium in pre- and post-HELP patient groups. To correct for the clustering of patients within wards and for baseline characteristics, multi-level analysis using the R statistical package will be used to evaluate differences in treatment outcomes between the two groups . EstimatMissing data will be corrected using multiple imputation.The aim of the qualitative research question is to incorporate viewpoints to be included in future HELP-training protocols and HELP-manuals for Dutch institutions that want to implement HELP. This information will enhance the chance of a successful implementation.The qualitative study will use a grounded theory approach to analyze the experiences of patients and HELP-team members. Grounded research combines two data analysis processes; all data are coded and systematically analyzed to verify or prove a proposition . The resDifferences in total mean costs between groups will be related to the differences in the number of cases of delirium and of the QALYs gained after three months. QALYs will be calculated by multiplying the utility of a health situation by the time spent in these health situations. The incremental cost effectiveness ratio (ICER) will be calculated and graphically presented as a scatter of bootstrapped ICERs on the cost-effectiveness plane and as an acceptability curve for a series of willingness to pay ceilings. Sensitivity analyses will be conducted that will focus on the most salient cost-drivers.This is the first study to implement and study efficacy and cost-effectiveness of the Hospital Elder Life Program (HELP) in the Netherlands. HELP has proven (cost-)effective in the US and Canada, and for that reason, the project group decided to stay as close to the HELP protocols as possible when implementing HELP in the Dutch hospital care system. Necessary adjustments, including a more involved role for the nurses and specific delirium screening methods, were discussed with and approved by Dr. Inouye, the developer of HELP.A controlled clinical trial with prospective, individual matching to compare patients admitted to one intervention and two usual-care (control) units was used in the original HELP study . RandomiIn the Netherlands, screening for delirium in older people has been a quality of care indicator of the Dutch Health Care Inspectorate (IGZ) since January 2010. As a result, hospitals are required to report delirium incidence and to develop policies on delirium prevention . Our datAlthough delirium screening is part of regular care, the protocols are not always followed; this study may improve the percentage of screening for delirium. Thus, an increase in the number of patients with delirium risk is expected, most likely resulting in more delirium diagnoses. Three months prior to the start of the study, the researchers will pay close attention to the measurements that should be part of regular care to achieve the same starting point for all units. This coordinated effort will result in reliable baseline data on delirium risk and delirium diagnosis in all participating hospital units. If HELP proves to be effective, the chance of implementation of the protocol is largely due to the alignment of the aims with screening regulations and developments in health care standards.Much attention will be paid to the recruitment, selection, training and coaching of volunteers. These individuals will receive a two day training and support from volunteer coordinators; a meeting will be organized every three months to allow the volunteers to share and evaluate their experiences. Before and after their activities, volunteers will also need to exchange information with nurses, which involves a change in the nurses’ work. The accessibility of the nurses will require attention from the project group.A concern is the participation of an adequate number of older patients. The literature suggests that in older people, the refusal rate is higher than in younger populations. Several possible causes for this factor have been suggested. One reason described is that a lengthy and complicated patient letter with risks and benefits can be difficult to read and understand for frail older people . The MedHELP requires a fundamentally different view on the care organization and a change in the care process, including the introduction of methods of early recognition combined with care plans and the introduction of an Elderly Care Nurse Practitioner and trained volunteers to provide additional psychosocial support. Results of one cost-effectiveness study  showed tThis research project aims to quantify the efficacy and (cost-) effectiveness of the Hospital Elder Life Program (HELP) in the Dutch health care system. The project will be extended with a qualitative study to describe and understand the experiences of patients, families, professionals and trained volunteers. HELP is unique in its approach by being patient-friendly, oriented to the wishes and needs of the older patients and guaranteeing additional psychosocial support. If HELP is proven (cost-) effective in this study, we will initiate knowledge transfer and implementation on a national level.The authors declare that they have no competing interests.MS drafted this manuscript. MS, BS, RM and SI were actively involved in writing the manuscript. All authors read and approved the final manuscript.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2318/13/78/prepubStepped-wedge design.Click here for file


To ascertain good and appropriate healthcare for both women and men implementation of gender perspectives in medical education is needed. For a successful implementation, knowledge about students' attitudes and beliefs about men, women, and gender is crucial. The aim of this study was to compare attitudes to gender and gender stereotyping among Dutch and Swedish male and female medical students.In this cross-sectional study, we measured the attitudes and assumptions about gender among 1096 first year medical students (616 Dutch and 480 Swedish) with the validated Nijmegen Gender Awareness in Medicine Scale (N-GAMS). The response rate was 94% in the Netherlands and 93% in Sweden. Univariate analysis of variance (ANOVA) was used to compare the scores between Dutch and Swedish male and female students. Linear regressions were used to analyze the importance of the background variables.There were significant differences in attitudes to gender between Dutch and Swedish students. The Swedish students expressed less stereotypical thinking about patients and doctors and the Dutch were more sensitive to gender differences. The students' sex mattered for gender stereotyping, with male students in both countries agreeing more with stereotypical statements. Students' age, father's birth country and mother's education level had some impact on the outcome.There are differences between cultures as well as between men and women in gender awareness that need to be considered when implementing gender in medical education.This study suggests that to arouse the students' interest in gender issues and make them aware of the significance of gender in medical work, the examples used in discussions need to be relevant and challenging in the context of the specific country. Due to different levels of knowledge and different attitudes within the student population it is important to create a climate for dialogue where students feel permitted to disclose their ideas and attitudes in order to become aware of what these are as well as their possible consequences on interaction and decision-making in medical work. Differences between men and women regarding biology, living conditions, behaviours and risk-taking are important causes of gender disparities in health and illness ,2. The iAs the importance of gender in health care has become established knowledge, attention has been paid to the implementation of gender issues in medical schools. Research reports and political documents are pointing towards the need for gender perspectives in medical education in order to ascertain good and appropriate health care for both men and women and increase future doctors' gender awareness ,10. GendIn most countries and medical schools the process of including gender aspects in medical curricula has started only recently. Reports from Canada, the Netherlands, Sweden and Australia describe the achievements and work undertaken, for example in pedagogy and the development of databases with paper-cases that incorporate gender aspects ,13-15. TThe Netherlands and Sweden are two countries in the front row when it comes to implementing gender within medical education. The need for gender perspectives in medical curricula has been acknowledged at governmental level in both countries. The Dutch Ministry of Health initiated a nationwide project for implementing gender issues in Dutch medical schools in 2002; the project had its centre at Radboud University, Nijmegen Medical Centre . In SwedEven though the Netherlands and Sweden are both wealthy European countries, gender relations in the two countries show differences. The Dutch two-third earner model implies that men work full-time while women work part-time and take care of their own children or grandchildren . Dutch wFeminist research argues that social policies in different countries can be seen as representations of gender values and ideology on a structural level . Social This study had a cross-sectional design and data were collected by a questionnaire. First-year medical students at Umeå University in Sweden, from autumn 2006 to spring 2009 , and at Radboud University Nijmegen Medical Centre in the Netherlands, during 2006-2007 , were invited to participate. The students were informed about the study when attending an ordinary lecture during the first week in medical school. Participation was voluntary and those who agreed to participate stayed on after the lecture to anonymously answer the questionnaire. The Ethical Committee at Umeå University has approved this study.The questionnaire measured gender awareness by means of the Nijmegen Gender Awareness in Medicine Scale (N-GAMS), previously elaborated in the Netherlands by way of exploratory factor analyses . ReliabiThe questionnaire also contained questions about the students' and their parents' socio-cultural background, i.e., students' sex, age, country of birth, civil status and whether they had children or not, and parents' country of birth, educational level and working time. The educational level of the parents was divided into three categories: "primary" when the highest education was primary school, "intermediate" when the highest education was secondary or intermediate secondary school, and "higher" for higher secondary school or university. The parents' working time was reported as "no paid work", "part-time" (< 36 hrs/week) or "full-time" (≥ 36 hrs/week).To check the N-GAMS scale for our sample including both Dutch and Swedish medical students, exploratory factor analyses were performed. The three-factor structure was confirmed, the new item loaded as expected together with the other GRI-D statements, but seven other statements were excluded due to low factor loadings (< .4) or cross-loading Table . Factor Univariate analysis of variance (ANOVA) was used to compare results from multiple groups. The N-GAMS scores between Dutch and Swedish male and female students was compared and interaction effects between country of study and student's sex was analysed.To analyse the relationship between the socio-cultural background variables and outcome on subscales of the N-GAMS we performed linear regressions since the outcome variables are interval variables. We used a model with students' and parents' background variables as independent variables and the outcome on GS, GRI-P and GRI-D as dependent variables. Since ANOVA showed differences between the Dutch and Swedish students we stratified our analyses by country. All statistical analyses of the data were performed in SPSS 17.0.In total 1096 (616 Dutch and 480 Swedish) students participated in the study, a response rate of 94% in the Netherlands and 93% in Sweden Table . The resThe students' age ranged from 16 to 50 years (M = 21), the Swedish students were older than the Dutch (M = 23 years versus M = 19 years) and the age span was larger in Sweden. There were more female students in both samples but the preponderance of women was considerably more pronounced in the Netherlands, where about 70% of the participants (and eligible students) were women. It was more common that Swedish students were cohabiting or married, had children, or that they reported a sexual orientation other than heterosexual, compared to the Dutch peers. In both Sweden and the Netherlands the proportion of students with a mother or father born abroad was small, and in both countries the non-native parents had their origin in many different countries in Europe, Asia, North America, South America and Africa (not shown in table). The parents' level of education was higher in Sweden than in the Netherlands and the difference was especially large between the Swedish and Dutch mothers. Concerning parents' working status, a large difference was also found between the mothers. A majority of the Swedish students had full-time working mothers but the most common among the Dutch was that mothers worked part-time.Since none of the Dutch students had children this variable was excluded in further analyses.The outcome on N-GAMS showed significant differences between Dutch and Swedish students on all three subscales when compared by ANOVA Table . The DutWhen exploring whether the socio-cultural background variables were related to outcome on GS, GRI-P and GRI-D, linear regressions stratified by country were used. Within this model Table  age was 2 in Table However, as indicated by RThe Dutch and Swedish medical students differed in gender awareness and showed significant differences in outcome on all three N-GAMS subscales. Dutch students reported higher gender sensitivity but they also expressed more gender-stereotypical attitudes towards patients and doctors. There were differences between men and women in stereotypical thinking, and in both countries female students disagreed more with stereotypical statements about patients. The pattern was that Swedish female students expressed the least stereotypical thinking, followed by Swedish male students, Dutch female students and finally the Dutch male students. The students' age had some impact on outcome in both countries, father's country of birth was related to gender sensitivity among the Dutch students, and mother's education was related to stereotypical thinking among the Swedish students.Data for this study were collected during the students' first week in medical school, implying that the results mirror the gender awareness the students had when entering their studies. The large sample and high response rate was a strength.N-GAMS was carefully elaborated and validated in a Dutch context , but ourUsing a scale as a tool for exploring gender attitudes and stereotypes obviously has both strengths and limitations. The N-GAMS scale was suggested to be used for research purposes and to evaluate gender awareness raising courses and one obvious strength with using such an instrument is that a large number of medical students could be included in the study. We also found that N-GAMS could be translated and used outside the Netherlands, meaning that the instrument makes it possible to compare medical students in different countries and cultural settings. However, the methods needs certain reflection; when understanding the differences we found between Dutch and Swedish students the background variables used in the questionnaire do not in themselves explain the results. Still, the significant differences in students' characteristics Table  provide The fact that the students in Nijmegen compared to the students in Umeå were more sensitive to gender differences and also more gender stereotyping of patients and doctors might have different explanations. Since the students came from all over Sweden and the Netherlands and answered the questionaire during their first days of medical school it is reasonable to believe that the differences reflect national differences rather than University differences. As outlined in the introduction, Sweden and the Netherlands are both welfare states, but the Netherlands has less far-reaching gender equality legislation and a more obviously gendered distribution of chores and duties than Sweden ,20,23. Care, for example that patients or doctors of one gender are "better", "too much" or "less", compared to the opposite gender  of medical students , and witProportions of women in full-time work and educational level in both men and women are often used as indicators of gender equality in a country ,20,23. WIt is well described in research that prevailing norms and beliefs about gender in a society are created and maintained by multiple, complementary processes acting simultaneously and at different levels of analysis, e.g., individual, societal, political, normative and cultural levels ,24,25. CIt is important to know the students' attitudes as a take-off point in the implementation of gender in the medical curricula ,17. DiffIn our study the male students agreed more with gender-stereotypical statements about patients than their female peers, which is in line with previous research showing that men to a larger extent than women hold on to gender-stereotypical ideas ,24. EarlSince gender-stereotypical assessments might lead to bias and misjudgements of patients, as well as misunderstandings in collegial cooperation, it is important to find out how to help students to reduce judgments that are grounded in stereotypes ,12. ReflOur experiences from gender education indicate that, parallel to the importance of good examples to discuss and reflect on, it is crucial to create a climate for dialogue where students feel permitted to disclose ideas and attitudes, including such ideas as are not "politically correct" in a specific context. If problematic ideas and reactions are not disclosed, the students' chances to catch sight of their own attitudes and values, and to discuss them, will be small and as a result the education will have less impact. On the other hand, when a student realizes that her/his own, or other students' or staff members', values and preconceptions might lead to problems for patients, then s/he usually becomes curious and interested.Further research about the effects of gender perspectives in education on students' attitudes and behaviour need to focus the gender topics included as well as the education methods used.This study shows that the Nijmegen Gender Awareness Scale in Medicine (N-GAMS) can be used for international comparisons of medical students' attitudes and values concerning gender.There are differences between cultures as well as between men and women in gender awareness that need to be considered when implementing gender in medical education.Based on these results we suggest that to arouse the medical students' interest in gender issues and make them aware of the significance of gender in medical work it is crucial that the examples used in discussions are trustworthy, relevant and challenging in the context of the specific country. Due to different levels of knowledge and different attitudes within the student population it is important not only with good examples to discuss and reflect on, but also to create a climate for dialogue where students feel permitted to disclose their ideas and attitudes in order to become aware of what these are as well as their possible consequences for their future profession.The authors declare that they have no competing interests.All five authors have made contributions to the study design, acquisition and interpretation of data. TLJ and KH was responsible the Dutch and Swedish data respectively. JA was responsible for the coordination of data and performed the statistical analysis. PV developed and validated the N-GAMS scale and made substantial contributions to the analysis. JA drafted the manuscript and EJ and KH assisted in writing the manuscript. All authors have been involved in revising the manuscript critically for important intellectual content and have read and approved the final manuscript.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1472-6920/12/3/prepub


Klebsiella rhinoscleromatis is said to be the cause. A female patient aged 45 years, presented with a past history of trauma to the nose and swelling on her nose since last 1 year. There was nasal asymmetry and internal nasal examination showed a septal swelling protruding to the right nasal cavity with hypertrophied nasal mucosa and inferior turbinate. Open tip rhinoplasty approach was used to excise the mass, which examined pathologically revealing a rhinoscleroma, fibrotic infiltrative stage.Rhinoscleroma is a chronic granulomatous condition of the nose and other structures of the upper respiratory tract. Infection by the bacterium  Klebsiella rhinoscleromatis. The Polish surgeon Johann von Mikulich in Wroclaw described its histological features in 1877. and von Frisch identified the organism in 1882. In 1932, Belinov proposed the use of the term scleroma respiratorium because the pathological process in rhinosclerosis may involve not only the upper but also the lower airways. In 1961, Steffen and Smith demonstrated that K rhinoscleromatis conformed to Koch’s postulates and that it was an aetiologic factor in the inflammatory changes typical of scleroma. The occurrence of familial disease suggests that genetic control of the host response to K rhinoscleromatis may be an important factor in endemic areas.[1Rhinoscleroma is a chronic granulomatous condition of the nose and other structures of the upper respiratory tract. Rhinoscleroma is a result of infection by the bacterium Rhinoscleroma is contracted by means of direct inhalation of droplets or contaminated material. The disease probably begins in areas of epithelial transition such as the vestibule of the nose, the subglottic area of the larynx, or the area between the nasopharynx and oropharynx.4A female patient, aged 45 years, presented to the outpatient clinic of Sohag Teaching Hospital with a past history of nasal trauma and swelling in the nose since last one year. The swelling was of not increasing in size and was associated with unilateral nasal obstruction, but no episatxis, nasal dryness, crustation, or other nasal symptoms. No other respiratory symptoms or past history of nasal symptoms were present.General examination showed no fever, no hypertension or diabetes mellitus. On local examination:-, the swelling was in the right side and in the tip of the nose, of 3 × 5 cm in size, firm in consistency, with an ill -defined border and disfiguring the shape of the nose . InternaBecause the complaint of the patient was nasal disfigurement, and the nature of the swelling was not known, medical treatment was not considered. The presentation was not conclusive of infectious disease, so the patient was prepared for excisional biopsy.Through an open rhinoplasty incision a surgical excision was planned. The swelling was originating from the septum and the right upper lateral cartilage with a -well-defined plane of cleavage as shown in Reconstruction of both the septal and upper lateral cartilage defects was done by use of conchal cartilage graft, spreader and strut cartilage grafts were done. Nasal pack of Vaseline gauze was introduced for 24 h, and the collumellal stitches were removed on day 5 post operatively.The histopathology of the specimen showed rhinoscleroma, fibrotic infiltrative stage.The patient received antimicrobial drug in the form of ciprofloxacin, 750 mg twice daily, for 1 week post operatively. Follow up for 3 weeks, 3 months, and 6 month post operative revealed a good functional and aesthetic outcome with no recurrence .K. rhinoscleromatis), a gram-negative diplobacillus localized electively in the upper airways, particularly the nasal fossae, leading to the term “rhinoscleroma”. Rhinoscleroma is a rare disease and consequently national and international epidemiological data are scarce. It has been reported in 168 countries, mostly from Central Europe, extending into Ukraine and around the Black and Caspian Seas.[K. rhinoscleromatis is not enough for the development of the disease, as contact of the patient with healthy individuals for many years may not necessarily bring about the infection in the latter. This has led to the suggestion that susceptibility of the host is important in the development of the disease. Impaired cellular immunity seems to be a major culprit.[Rhinoscleroma is a specific chronic granulomatosis disease caused by enterobacteria of the Klebsiella family  have hu culprit. CellularRhinoscleroma usually affects the nasal cavity, but lesions associated with rhinoscleroma may also affect the larynx, nasopharynx, oral cavity, paranasal sinuses, or soft tissues of the lips, nose, trachea, and bronchi. The diseUntreated rhinoscleroma tends to progress slowly over many years, characterised by periods of remissions and relapses. During the earlier stage of the disease, adherent white plaques and granulations of different sizes may be seen in the airway. A culture of this material will have a high yield for the organism.Although our patient was diagnosed at a later stage due to her low socioeconomic status and neglect, she did not give a history of crustation or discharge. The nasal septum is an uncommon site for rhinoscleroma, and the patient presented a history irrelevant to the disease, but the histopathological examination surprisingly diagnosed it as rhinoscleroma.Open tip rhinoplasty was a good approach for excising the swelling and also for the reconstruction to be done with ease.