After a mobile health  app is created, an important step is to evaluate the usability of the app before it is released to the public. There are multiple ways of conducting a usability study, one of which is collecting target users’ feedback with a usability questionnaire. Different groups have used different questionnaires for mHealth app usability evaluation: The commonly used questionnaires are the System Usability Scale (SUS) and Post-Study System Usability Questionnaire (PSSUQ). However, the SUS and PSSUQ were not designed to evaluate the usability of mHealth apps. Self-written questionnaires are also commonly used for evaluation of mHealth app usability but they have not been validated.The goal of this project was to develop and validate a new mHealth app usability questionnaire.An mHealth app usability questionnaire (MAUQ) was designed by the research team based on a number of existing questionnaires used in previous mobile app usability studies, especially the well-validated questionnaires. MAUQ, SUS, and PSSUQ were then used to evaluate the usability of two mHealth apps: an interactive mHealth app and a standalone mHealth app. The reliability and validity of the new questionnaire were evaluated. The correlation coefficients among MAUQ, SUS, and PSSUQ were calculated.In this study, 128 study participants provided responses to the questionnaire statements. Psychometric analysis indicated that the MAUQ has three subscales and their internal consistency reliability is high. The relevant subscales correlated well with the subscales of the PSSUQ. The overall scale also strongly correlated with the PSSUQ and SUS. Four versions of the MAUQ were created in relation to the type of app  and target user of the app (patient or provider). A website has been created to make it convenient for mHealth app developers to use this new questionnaire in order to assess the usability of their mHealth apps.The newly created mHealth app usability questionnaire—MAUQ—has the reliability and validity required to assess mHealth app usability. Mobile health  apps can be used to perform tasks in areas such as wellness management, behavior change, health data collection, disease management, self-diagnosis, and rehabilitation as well as act as an electronic patient portal and medication reminder ,2. A numno highly reliable usability questionnaire has been specifically designed for mobile apps.Among several methods for evaluation of mobile app usability, the usability questionnaire is the most frequently used because of its simplicity in terms of execution and data analysis. Ironically, although millions of mobile apps have been created and released to the public in the past decade , no highusability models because of the special components in mobile apps such as small form factors, connectivity issues, battery issues, limited computation power, and the unique security and privacy challenges associated with highly portal mobile devices [There have been studies on creating new mobile app  devices ,10.Studies have also tried to adjust existing usability frameworks and questionnaires, so that the models can be used for evaluation of mobile app usability ,12. HoweBoth choices have their advantages and disadvantages. The advantage of the former case is that the questionnaires have been used in many other studies, and therefore, certain usability aspects of the mobile app can be reliably measured. Frequently used usability questionnaires are the System Usability Scale (SUS) and Post-Study System Usability Questionnaire (PSSUQ) ,14. HoweIn the second case, when authors create their own usability questionnaire, they have the flexibility to cover the unique features offered by their mobile apps; however, because the major focus of those usability studies was not on validation of their self-written questionnaires, the authors typically only recruited a small number of study participants; therefore, the obtained data were not sufficient for a reliable psychometric analysis. In other words, the reliability and validity of results from the latter usability studies are questionable. Therefore, there is a need to create a reliable usability questionnaire specifically for mobile apps. This study will specifically focus on creating an mHealth app usability questionnaire.When designing a user-based mHealth app usability questionnaire, one has to consider the type of users and type of mobile apps.purpose for using the app. Here, patients are people who use an mHealth app to maintain, improve, or manage their own health, while health care providers are people who use an mHealth app to deliver health care services such as medication prescription, laboratory ordering, consultation, and patient education. In the usability questionnaire, certain words need to be customizable to reflect different target users of mHealth apps.All mHealth apps can be arranged into one of two categories according to the type of target users: patients or health care providers. The type of user is not determined by the occupation of the user, but rather by the interaction between the patients and health care providers in the app: interactive mHealth apps and standalone mHealth apps. In interactive mHealth apps, the app users can send and receive information from their health care providers or patients via the app. The communication between patients and providers can be synchronous or asynchronous. In standalone mHealth apps, the app users enter/collect/store health information about themselves or other people. The standalone apps may generate reminders or show a summary or details about the collected health information, but these apps do not send the data to the user’s health care providers or patients. In other words, the major difference between these two types of apps is the level of interactivity. For interactive mHealth apps, there is direct interaction between patients and their health care providers. Therefore, the questionnaire for interactive apps should have statements about the quality of interaction, while the questionnaire for standalone apps may not need those statements.The mHealth apps can be further grouped according to the nature of the four different versions of the mHealth app usability questionnaire are needed to evaluate the usability of mHealth apps designed for different users  and different interaction modes .Hence, In this study, the goal was to create a short, reliable, and customizable (via four different versions) questionnaire for assessing the usability of mHealth apps.To create the desired questionnaire, we reviewed a large number of published papers about mHealth apps and then created an mHealth app usability questionnaire (MAUQ) based on the questionnaires used in these published studies, taking into consideration the uniqueness of mobile devices and mHealth apps. We then used this newly developed questionnaire in a usability study on two mHealth apps. A psychometric analysis was performed to evaluate the reliability of the MAUQ as well as the correlation between the results from the MAUQ and those from the SUS and PSSUQ.To design the desired mHealth app usability questionnaire, we first used the keywords “mobile app” and “usability” to search for published usability studies on mobile apps in PubMed, CINAHL , IEEE Xplore, ACM Digital Library, and InSpec . From thunique questionnaire statements (including similar statements with different wording) from these 38 questionnaires and arranged them into categories according to the general guidelines for usability assessment and the unique features of mobile apps. The categories included items such as usefulness, ease of learning, ease of use, effectiveness, satisfaction, interface quality, interaction quality, reliability, error messages and online support, internet connectivity, and social settings of mobile app use [relevance and clarity of these statements on a scale of 1-4, where 1 indicates no relevance or clarity and 4 indicates high relevance or clarity. If four or more usability experts rated the relevance of a statement 1 or 2, it was removed from the questionnaire. If any one of the usability experts rated the clarity of a statement 1 or 2, the wording of the statement was adjusted. After this step, 53 statements remained in the questionnaire, 19 of which needed the wording to be adjusted.We collected 312  app use ,24-26. TAfter the necessary adjustments to the 19 statements, the research team held several face-to-face meetings with the seven usability experts to extensively discuss each of the 53 statements remaining. At the end of the discussion, the entire research team decided to reduce the number of statements for interactive mHealth apps to 21 and the number of statements for standalone mHealth apps to 18.In this step, we recruited a group of study participants to take part in usability studies using this new questionnaire (MAUQ) and two commonly used usability questionnaires (PSSUQ and SUS). The data obtained from this study were used to evaluate the reliability and validity of this new questionnaire. After the new usability questionnaire was ready, a usability study on mobile apps was designed using the newly developed MAUQ and two widely used usability questionnaires, PSSUQ and SUS. Each of the study participants was asked to first use two mHealth apps: one was an interactive mobile app—iMHere 2.0 ,27,28—anDuring the study, a general introduction to the purpose of the study and the two mHealth apps (iMHere 2.0 and Fitbit) was provided, along with a brief demo of these two mHealth apps and an explanation of the new usability questionnaire MAUQ. After the introduction, the study participants were asked to finish several tasks using these two mobile apps and provide responses to the three usability questionnaires  through the Web-based Qualtrics survey system . The demographic information of the study participants was also collected during this usability study via the Qualtrics system. Statistical analysis was performed on the collected data. This study protocol was approved by the institutional review board office at the University of Pittsburgh. A brief description about iMHere 2.0 and Fitbit apps and the tasks completed by the study participants in the usability study are provided below.The iMHere 2.0 system has multiple major components, including a mobile app for patients and a Web portal for clinicians. Patients can use the mobile app to perform a number of self-care tasks such as managing their medication schedules, reporting minor skin issues, performing mental health self-assessment, tracking physical activities and nutrition, sending messages to clinicians, receiving messages from clinicians, and receiving brief education in health-related topics. Clinicians can use the Web portal to view all the entered patient information and communicate with patients. Clinicians can also issue or change interventions for patients via the Web portal, which are reflected on the mobile app for patients in real time. Therefore, this mobile app in iMHere 2.0 is considered an interactive mHealth app.The Fitbit app accompanies the Fitbit wearable device. It can display the data collected by the wearable device, such as the number of steps, heart rate, and sleep duration. The user can also enter some data that cannot be collected by the device, such as food and drink consumed in a day. Although the Fitbit app has some social media features, the user cannot directly communicate with his/her health care provider via the app. Therefore, this Fitbit app is considered a standalone mHealth app.When using the iMHere app, study participants were asked to finish four tasks: (1) schedule a reminder for taking medication in the MyMeds module of the app; (2) report a skin problem in the Skincare module; (3) add medical history records such as medication history, allergies, immunizations, social history, and family medical history in the Personal Health Record module; and (4) adjust settings of the app, such as making the font bigger or changing the personal profile picture. The app would generate a reminder according to the indicated time point in the medication reminder schedule, and the study participant was required to respond to the reminder. After the study participants reported one skin problem, the data would show up on a Web-based clinician portal, a clinician provided a response to the subject, and the information was shown in the message section of the iMHere 2.0 app. Study participants were required to read the message and could choose to reply to the clinician, if necessary.When using the Fitbit app, study participants were asked to finish the following tasks: determine the numbers of steps and distances walked in the past week and past month; check their sleep history and add one new sleep log; add one new record about food eaten that day; add one new record about beverages they had drunk that day; check messages received in the app; and change the setting of goals such as the desired number of steps, number of sleep hours, and current and desired weight.Participants were recruited through flyers distributed in the Greater Pittsburgh area and at the Pitt + Me website at the University of Pittsburgh . ParticiResponses to the statements on the MAUQ and PSSUQ ranged from 1 (strongly agree) to 7 (strongly disagree). The responses to the statements on the SUS ranged from 1 (strongly disagree) to 5 (strongly agree). Nine  study participants missed one to a few statements, and the other 119  study participants provided responses to all the statements on the MAUQ. In our analysis, we used a value of 4 (indicating neither agreement nor disagreement) to fill the position of the missing data for the MAUQ.A descriptive analysis was first performed on the collected data to gain an understanding of the demographic characteristics of the study participants and the overall performance of the three usability questionnaires . The means and SD for individual statements and the entire questionnaire for the MAUQ and PSSUQ were calculated. The PSSUQ version 3 used in this study had 16 items, where items 1-6 were the first subscale (PSSUQ1), items 7-12 were the second subscale (PSSUQ2), and items 13-15 were the third subscale (PSSUQ3) ,31. The The correlation coefficients among the scores obtained using the MAUQ, PSSUQ, and SUS were calculated, including the correlation coefficients of their subscales, if applicable, and the intersubscale correlation coefficient within the MAUQ. The former correlation coefficients were to be used to determine the criterion validity of the MAUQ, while the latter were to be used to determine the construct validity of the MAUQ . In the An exploratory factor analysis (EFA) was performed on the data collected from all study participants using the MAUQ. We expected multiple factors for the MAUQ and that these factors would not be totally independent. Therefore, we used maximum likelihood as the method for factor extraction and quartimin with Kaiser Normalization for oblique rotation in EFA . The facTo evaluate the internal consistency of the MAUQ, we calculated the values of Cronbach alpha for the entire questionnaire and its subscales. Cronbach alpha is a commonly used measurement of internal consistency for questionnaires. For research and exploratory studies, Cronbach alpha values of 0.7-0.8 are acceptable, while a value of around 0.9 is excellent .All these statistical analyses were performed using R 3.3  and IBM SPSS, version 24 .In total, 128 participants were recruited from the Greater Pittsburgh area for the study. The demographic information of these participants is summarized in P<.01. Therefore, when evaluating the impact of demographic characteristics on the answers in the MAUQ, we used a nonparametric Kruskal-Wallis test. The test results indicated that none of the demographic factors  had a statistically significant impact on the answers to the individual statements or the overall score on the MAUQ .The distribution of data from the MAUQ-based usability study was not normal according to both the Shapiro-Wilk test and the Kolmogorov-Smirnov test, where It was easy for me to learn to use the app”) were smaller than 0.32; however, according to our experience working with usability studies and evidence from numerous other previous studies, we believe this statement is very important for a mobile app usability study and is closely related to the ease of use statement and the design of the interface. Therefore, we decided to retain this statement in the first construct of the questionnaire.The three factors correspond to three constructs, or subscales, on the MAUQ: ease of use and satisfaction , system information arrangement , and usefulness . Their Cronbach alpha values were 0.895, 0.829, and 0.900, respectively, which indicate strong internal consistency.health care, which is not covered by the PSSUQ. For overall scores, the MAUQ is strongly correlated with the PSSUQ (r=0.8448) and also correlated with the SUS (r=0.6425). The correlation between the overall scores of the PSSUQ and the SUS is 0.6703. These correlation coefficient values show the criterion validity and construct validity of the MAUQ.The correlation coefficients among the scores of the MAUQ, the scores of the MAUQ’s three subscales, the scores of the PSSUQ and its subscales, and the score of the SUS are shown in For the MAUQ designed for standalone apps, a similar analysis was performed and again, three factors were found. We noticed that there were a few cross-loading items  when 0.32 was used as the cut-off value of factor loadings. We chose not to remove these items, since our experience and numerous other usability studies indicate the importance of measuring overall satisfaction, information organization, time spent on the app, and usefulness of the app. In the future, we will conduct studies with larger samples to further evaluate these statements and determine whether they should be kept in the standalone mHealth app usability evaluation.The results for the EFA and correlation coefficient calculation are shown in Statements on the mHealth App Usability Questionnaire adjusted for interactive mobile apps designed for health care providers:deliver health care services.I10. This app provided an acceptable way to care practice.I15. The app would be useful for my health delivering health care services.I16. The app improved my access to patients’ health effectively.I17. The app helped me manage my patients.I18. The app made it convenient for me to communicate with my patients.I19. Using the app, I had many more opportunities to interact with my patients using the app will be received.I20. I felt confident that any information I sent to my patients using the app.I21. I felt comfortable communicating with my Statements on the mHealth App Usability Questionnaire adjusted for standalone apps designed for health care providers:health care practice.S13. The app would be useful for my delivering health care services.S14. The app improved my access to patients’ health effectively.S15. The app helped me manage my deliver health care services, such as accessing educational materials, tracking my own activities, and performing self-assessment.S18. This mHealth app provided an acceptable way to receiving health care services to delivering health care services, and from interacting with health care providers to interacting with patients. Further evaluation may be needed for the health care provider version, since the two mHealth apps in this study were both for patients. In the versions of the MAUQ questionnaires described in the previous sections, some statements were generic, while some statements were specific to mHealth apps designed for patients. When evaluating the usability of mHealth apps designed for health care providers, some statements need to be slightly modified, for instance, changing the statement from To make it convenient for others to utilize the MAUQ in their mHealth app usability studies, we created a website  that incThe aim of this study was to develop and validate a new mHealth app usability questionnaire—the MAUQ. This new questionnaire is highly reliable , as we used information gathered and summarized from many previous studies and combined the experience of several usability study experts to create it. Below is a summary of the unique contribution of our work.First, the development of the MAUQ was based on a number of usability questionnaires used in mHealth app usability assessment described in published journal articles. Some of these questionnaires are well validated, and therefore, many statements in these questionnaires have been approved in numerous studies, making the use of a great resource a better choice than creation of a new questionnaire completely from scratch.Second, the draft of the MAUQ was created considering components specific to mobile devices and mHealth apps. Some proposed mHealth app usability models were also consulted while questionnaire statements were being selected. This makes the MAUQ an mHealth app–specific questionnaire.Third, a group of usability experts discussed the draft of the questionnaire and built the draft of the MAUQ. These usability experts had extensive experience in the study of mHealth app usability, and therefore, their knowledge and experience were integrated into the MAUQ during the discussion and questionnaire statement selection.Fourth, four different versions of the MAUQ were created for four different scenarios . This makes it feasible for others to easily choose one version for their usability study according to the desired context.Fifth, this newly built questionnaire was tested in a usability study with 128 study participants and two mHealth apps—one, standalone (Fitbit) and the other, interactive (iMHere 2.0). This sample size is much bigger than typical usability studies; hence, it was feasible for an EFA. The data analysis results indicated that the MAUQ has strong construct validity and criterion validity, and the internal consistency of the three subscales and the entire questionnaire is high.Sixth, the performance of the MAUQ was compared with two frequently used usability questionnaires—PSSUQ and SUS. The correlation coefficients among the MAUQ, PSSUQ, and SUS were high because they all were used to measure the overall usability of the mHealth apps. Two subscales of the MAUQ were also highly correlated with two subscales of the PSSUQ measuring similar aspects of usability. For the MAUQ subscale, with features unique to mHealth apps, the correlation was not that strong with any of the PSSUQ subscales, which is expected. In other words, the MAUQ can reliably measure usability of mHealth apps.According to our knowledge, there is no single highly reliable usability questionnaire specifically designed for mHealth apps. Researchers from other teams have investigated usability models for mobile apps and also tried to modify existing usability questionnaires for use in mobile app usability studies. However, to date, none of these have been widely adopted by other researchers.The 21 statements in the final version of the MAUQ for interactive mobile apps were compared with the ones in several other frequently used usability questionnaires. The result indicated that 5 statements in the MAUQ were highly similar to the ones in multiple other questionnaires; 10 statements in the MAUQ were similar to the ones in a few other questionnaires, but more specific to mobile app–based health care activities; and the remaining 6 statements were unique to the MAUQ.quality of mHealth apps [A few years ago, a mobile app rating scale (MARS) was created for assessing the lth apps , which ilth apps . Both MAOne recently published work adjusted an existing usability questionnaire to apply it for mHealth apps . In thatIn the MAUQ, we provide four versions for two types of target users (patients and providers) and two major types of mHealth apps , which allows MAUQ users to choose the version that fits their needs. Moreover, the website created for the MAUQ makes the administration of the usability questionnaire easy. Researchers and mobile app developers can easily use the website to perform a quick usability/feasibility study with a small number of participants on the prototype of their apps, to conduct a multistage usability study during the process of the app development, or to have a large-scale intensive usability study with many participants over a long period of time. In addition, all the collected data from these usability studies are stored securely on the website for viewing and downloading.The study was performed in the greater Pittsburgh area, but approximately one-third of the study participants were undergraduate and graduate students from different states, making the conclusions obtained in this study generalizable within certain limitations.In this study, we had more female participants. All the participants were randomly selected from eligible candidates, but there were significantly more female mobile app users who expressed interest in this study. In other words, this study population was not an exact reflection of the US population; however, it did indicate the distribution of mobile app users who were interested in using mHealth apps to take care of their health.The sample size (N=128) was considered sufficient for EFA, since the ratio between the number of study participants and the number of statements (n=21) was greater than 5. Since EFA is a large-sample procedure, a larger sample size provides more reliable results, for instance, to determine whether the items with low factor loading should be kept in the MAUQ for interactive apps and whether the cross-loading items should be removed from the MAUQ for standalone apps. For this reason, we will use this questionnaire in our usability studies to collect more data in the future. We also created a website to make it convenient for others to use this new questionnaire in their usability studies. We encourage others who use the MAUQ in their usability studies to share their collected data with us, so that we can perform further psychometric analysis on this questionnaire to improve its use for mHealth app usability evaluation.In this study, we required that the study participants had certain characteristics, such as a high school or higher education, age between 18 and 65 years, and some experience using mHealth apps. This excluded some potential participants, for instance, people older than 65 years or people with a low education level. However, since the purpose of this study was to evaluate the newly created usability questionnaire, the participants selected were representative of the majority of mHealth app users and ones who could provide the most reliable assessment on the questionnaire. A different usability study method may be used for populations not included in this study.slightly different for different mHealth apps. This can be assessed in the future after other research teams adopt the MAUQ in their usability studies with other mHealth apps.The usability study in this work was performed on two mobile apps: iMHere 2.0 and Fitbit. It is possible that the results might have been Only the patient versions of the MAUQ were tested in this study. Therefore, although we believe the differences in the versions for patients and the versions for providers are not significant, the versions of MAUQ for health care providers were not explicitly evaluated. In the future, we may identify appropriate interactive and standalone mHealth apps designed for health care providers and perform the usability study again to evaluate the versions for providers. We may also utilize usability study data from other research teams to perform further assessment on the versions for providers.


Bangladesh has an established comprehensive death review system for tracking and reviewing maternal and perinatal deaths. This death review system, established in 2010, was initially known as the “Maternal and Perinatal Death Review (MPDR) System.” One of the key interventions of the MPDR system, social autopsy (SA), is generally undertaken following a maternal or perinatal death notification. Social autopsy is managed at the community level by government field health workers. The main purpose of SA is to enable community discussion and create awareness of the preventable causes of maternal or neonatal deaths. Through these conversations, it is hoped to reduce future maternal and neonatal deaths. During the scaling up of the system in Bangladesh in 2016, the Ministry of Health and Family Welfare (MoH&FW) included social autopsy as a useful intervention in reviewing death at the community level and named it “Maternal and Perinatal Death Surveillance and Response” (MPDSR). The new MPDSR tool is currently being administered for the the 2017 to 2021 period under the National Health and Nutrition Population Sector Program (HPNSP). This paper seeks to review the experiences of the social autopsy tool, from the initial MPDR system to the current MPDSR system and its role in reducing maternal and neonatal deaths in Bangladesh. Social autopsy (SA) is an innovative tool, used worldwide, to determine the salient social determinants of death. There is much scientific research describing the remarkable achievements of SA in diminishing maternal and neonatal deaths, including stillbirths, in many low- and middle-income countries (LMIC) –3. SA isBeing a LMIC, Bangladesh has experience of implementing SA as a community-based intervention in preventing death from injuries such as road traffic accident, drowning, and also death as a result of communicable disease –10. In tThe system follows a cycle. When the government frontline health workers receive notification of a mother or newborn death, they conduct a verbal autopsy followed by SA . SA is aSA can help prevent death in the community by creating social awareness. The basic strategy is adopted from another intervention of child injury prevention in Bangladesh , 10. In The SA meeting is usually held between 15 and 30 days after the death. SA facilitation takes place in the courtyard close to the home of the deceased. Usually, the meeting starts with neighbors expressing their view of what contributed to the death of the mother or newborn. With the revelation of the scenario, community people interact with each other and express their own views and opinions and gradually understand the deficiencies in their knowledge . CommuniThe Health Inspector, Family Planning Inspector or Sanitary Inspector from both Health and Family Planning Departments of the Government are the key actors in conducting the first line supervision  to arrange the SA at the community level. The health workers, with the help of community group members, neighbors, and family members of the deceased along with the support of other grassroots level health workers, organize a community level meeting. The health workers receive training on facilitation of the community session and develop skills to explore the social causes, stigma, and barriers held responsible for a death of a mother or neonate in the community. By encouraging the community people to speak in their own words, the health worker guides them to understand how events could have been handled better. The health worker also conveys important messages related to maternal or neonatal complications, birth planning, essential newborn care, antenatal care, postnatal care, and available facilities in the government hospital for the mother and neonate. They also show visual materials like flip charts, documentaries, and other important behavioral change communication materials to the local community. Many of these people are illiterate, so these simple visual aids can assist them in making future sound decisions. The health workers also seek commitment from the community about what actions they will take if similar maternal or neonatal complications arise in the future .The main target group of the SA meeting is the neighbors of the deceased. There is a special focus on the head of the household. These are mostly male and an important consideration of a SA session as they are the family decision makers. To ensure the involvement of male members of the deceased, SA usually takes place in early morning or late afternoon to keep working hours uninterrupted.In a SA, around 40–50 participants gather, including the health worker as facilitator. During a session, community people discuss how the maternal or neonatal death occurred in their local neighborhood. Community members discuss the events that took place before the death of a mother or newborn such as health complications, health seeking behavior and delays in decision making, difficulties in transferring the patient, or delay in the provision of care at the facility level . The forIn each meeting, the health worker invites the community leader, who can be an elected person from local government, a school teacher, a religious leader, or a local elder to mobilize the society towards good practices. The presence of these people during the meeting helps to develop accountability for their community to act in the best possible way to prevent future maternal or neonatal death. Therefore, by the end of the session, the community develops a need-based action plan to implement in their village to try to prevent the occurrence of similar patterns of death. The action plan includes practical strategies such as arranging money and accessing transport during an emergency. The community group members make a commitment to support and implement the action plan while the community leader helps to evaluate the action plan implementation in the community . Within Many studies in Bangladesh have shown that SA is effective in exploring probable medical causes of death, as well as behavioral, environmental, and social causes . SA servFollowing discussion at the SA meeting, the community takes a number of decisions at the local level to address the factors responsible for a death. The World Health Organization guidelines for maternal death surveillance and response address the effective actions or responses to avert future maternal, perinatal, and neonatal deaths . In the Many notable scenarios have been identified where we have seen that SA created a change in the behavioral pattern of a family, into a practice . NowadaySA of maternal and neonatal deaths is an intervention platform for discussion and interaction between the community government health workers in Bangladesh. SA is not data-driven, and no tools are used for the collection of information. This creates avenues to understand community demands, knowledge gaps, and the challenges that need to be overcome by the community , 13. ThrIn Bangladesh, SA is being implemented by the government health system. In this way, the entire intervention is focused on reaching the government mandate of achieving SDG on time . NationaBy using community interaction and a participatory decision-making process, SA is a wonderful opportunity to prevent avoidable maternal and neonatal deaths.. SA is being implemented through the government’s ongoing MPDRS system in Bangladesh; therefore, at the local level, it has the opportunity to effectively address the desired SDG by 2030. Active participation of the community from the very beginning up to the end of the session builds up community accountability and encourages determination to implement their own action plans. With programs like SA, Bangladesh is on a good track to reduce maternal and neonatal morality,


Swedish as well as foreign publications have reported a sharp increase in firearm-related violence in Sweden. None of these publications, however, combined official statistics from the Swedish police, the National Council for Crime Prevention (NCCP), and the National Board of Health and Welfare (NBHW), to study firearm-related violence in the last 2 years: 2016–2017. The results of this study show that firearm-related violence in Sweden has greatly increased compared to other Scandinavian countries, especially in recent years. This is probably the reason for the increase in the rate of deadly violence. Further, the increasing number of gangs and criminal networks, as well as the high inflow of illegal firearms to Sweden, is believed to have contributed to the disturbing increase of firearm-related violence in the country. Although Sweden is one of the most democratic and freest countries in the world, and has some of the world’s strictest gun laws, the country still faces significant firearm-related violence. This study not only reveals the increasing rate of firearm-related violence in Sweden, but also shows that Sweden is in dire need of additional policies to combat the illegal flow of firearms and to curb gang criminality. Recently published international reports state that lethal and non-lethal firearm-related violence in Sweden has been increasing; and that Sweden has one of the highest rates of shootings and consequently the highest level of firearm-related violence in Western Europe ,2. SwediAlthough there are no studies or reports stating the contrary, many publications are either focused on a specific Swedish geographical location , have onThe Small Arms Survey  writes iBased on official statistics from three leading sectors in Sweden, this short research article, aims to evaluate for the first time, whether firearm-related violence in Sweden between the years 2016 and 2017 indeed increased, and what the main causes may have been if it had. A statistical comparison with other Scandinavian countries  will also be conducted.http://www.polisen.se), the National Council for Crime Prevention , and the National Board of Health and Welfare . These three sectors’ statistics and publications on deadly and firearm-related violence were retrieved and analyzed by comparing statistical rates and figures. The use of multiple and different official sources provides a comprehensive image of firearm-related violence in Sweden, thus diminishing the risk of selection bias.The three most important sectors that gather statistics on firearm-related violence in Sweden are the Swedish police  or Eurostat (https://ec.europa.eu/eurostat/web/main/home) were used.This study uses the national official statistics of other Scandinavian countries. In cases where this was not possible, statistics from the World Health Organization  were killed by a firearm [In a report on deadly violence, the NCCP writes that a firearm was used in close to 20% of all cases of homicide in the 1990s and until 2011. The rate of firearm use for the years between 2012 and 2016, however, increased to 28% in 2016 . The NCCA recent statistical report by the Swedish police , shows tStatistics from the NBHW shows that the number of individuals in Sweden injured by a firearm has greatly increased since 2009. Between 2012 and 2017, the number of individuals that were injured by a firearm increased by 50% . Figure A comparison of Sweden to other Scandinavian countries both in regard to deadly violence  and fireFinland had a total homicide rate of 646  between Statistics on homicide in Denmark are unfortunately difficult to find. In the present study, official statistics from suspected homicides reported to the Danish Police have been used, showing a total of 341 homicides between 2011 and 2017 [Statistics from the World Health Organization  show thaStatistics from the Swedish police, the NCCP, and the NBHW clearly show that the rate of firearm-related violence, including firearm-related homicides, has greatly and significantly increased in Sweden over the last decade, and not least from 2012 to 2017. This is probably the reason Sweden is also witnessing an increase in deadly violence.International reports , 2, the Although gangs and criminal networks have always existed in Sweden, street gangs flourished in the late 1990s and are today considered to be one of the main security problems in the country . SwedishAnother very important source of the increase of firearm-related violence in Sweden is the easy access to illegal firearms. Although Sweden was, for decades, shielded from firearm-related violence, mostly because of its restrictive gun laws, the easy access to illegal firearms, in addition to the many gangs and criminal networks in the country, is the main reason for the disturbing increase in the country’s rate of firearm-related violence. According to police reports, there has been a high inflow of illegal weapons into Sweden from the western Balkans .Sweden’s serious problem regarding illegal firearms and the many cases of shootings despite the country’s strict and restrictive gun laws, poses a new challenge for Sweden’s policy makers. Sweden’s restrictive gun laws are without a doubt the reason the country has been spared from school shootings and other types of mass shootings. These laws, however, have not succeeded in stopping the inflow and use of illegal firearms. Other countries should also be aware of this phenomenon. Restrictive gun laws must be combined with other policies and measures to fully curb firearm-related violence. At the same time, new and relatively more powerful policies are needed to combat gang criminality and gang violence.To combat the inflow of illegal firearms, Sweden’s policy makers should address three main problems: (1) the Swedish police force must increase their collaboration with the police forces of different countries in the Balkans from where most of the weapons to Sweden are smuggled; (2) the government must introduce stricter laws regarding the smuggling of weapons. These strict laws will partly interfere with the individuals’ criminal act by incarcerating the criminals, and partly allow the police and customs to use advanced surveillance methods—not otherwise allowed for crimes warranting a short period of imprisonment—to combat gangs and criminal networks; and (3) customs must be given additional authority to maintain more effective and viable border control.Regarding gang criminality and criminal networks, and the subsequent firearm-related violence, the situation is quite desperate in Sweden. The government and the police have significantly disrupted these criminal organizations. A stricter weapon law has been approved and implemented by the government, and the police and their intelligence unit have focused greatly on these gangs and networks. These actions may have a positive effect. However, one of the serious problems is that the participants in these criminal gangs and networks are young individuals who are promptly replaced by others whenever they get killed. This inflow of young criminals must be stopped and the way to do so is multifactorial.Acute measures must be taken to disrupt these criminal organizations and stop the cycle of firearm violence which is holding Sweden hostage. The most violent criminals must be apprehended, and to do so, the police need both more monetary and personnel resources, as well as new laws and regulations such as the so called “stop-and-search-zones” where the police in specific zones can stop and search every single individual without probable cause as is otherwise needed. Another regulation of interest would be the so called “no-access-zones”, which prohibit individuals from specific zones either indefinitely or during certain hours.In the long run, however, the police, schools, child and adolescent psychiatry, and social services require additional funds and resources. These institutions’ crime prevention effects must become more focused and more efficient, which is why a comprehensive education program in crime prevention is needed for these institutions. It is otherwise impossible for Sweden to stop criminal gangs and networks from recruiting youths, and consequently, maintaining the cycle of violence.


Objectives: The concern about elder abuse increases as the global population ages. Elder abuse is a global public health, human rights, and criminal justice problem that goes beyond socioeconomic classes and regions. It remains understudied, especially in developing countries with limited resources. It is therefore timely to do a review of the available research on elder abuse in South Africa, to be able to address the gaps in the research with future projects.Methods: Publications were identified from PubMed, MEDLINE, PsychINFO, Sabinet, Africa-Wide Information, CINAHL, E-Journals, Family and Society Studies Worldwide, PsycARTICLES, Criminal Justice Abstracts, and Social Work Abstracts. Fourteen articles on elder abuse in South Africa were selected for further review. This paper provides a narrative review of elder abuse in South Africa and is not a systematic review.Discussion: South Africa is a multicultural nation, plagued by HIV/AIDS, poverty, and the remaining effects of the legacy of apartheid. This background sets the stage for categories of abuse that are unique to the country that are highlighted in this review. The available research on elder abuse is very limited and no reliable data about the prevalence of elder abuse in South Africa could be found.Conclusions: There is a clear need for more longitudinal research about all aspects of elder abuse in South Africa. To improve future research efforts consensus has to be reached about a universal operational definition of abuse and an elder abuse instrument with a clear cut-off for definite elder abuse. As the global population ages, the number of people aged 60 years and older is estimated to reach 2 billion by 2050. This increase in the older population heightens the concern about elder abuse and neglect. Elder abuse is a global public health, human rights, and criminal justice problem. It goes beyond, socioeconomic classes, regions, languages, and ethnicities, but remains understudied, especially in developing countries with limited resources. Available evidence suggests that elder abuse is prevalent, predictable, costly, and sometimes fatal .Published figures of elder abuse and neglect varies greatly with ranges between 2 and 60%. An estimated overall prevalence of elder abuse of ~10% is considered reasonable, but is likely to be an underestimate. The prevalence of abuse in institutional settings are considered to be higher, with up to 64.2% of staff admitting to elder abuse based on self-report. Research has suffered from several weaknesses and has been hindered by the lack of consensus on a single universal operational definition of elder abuse and neglect, measurement problems, and inconsistent research methodologies , E-Journals, Family and Society Studies Worldwide, PsycARTICLES, Criminal Justice Abstracts, and Social Work Abstracts. The databases were searched using combinations of the following keywords: abuse, aged, elderly, elder abuse, assault, exploitation, maltreatment, neglect, South Africa.The inclusion criteria were: English-language articles reporting on abuse of people aged 60 years and older in South Africa. A ministerial committee of inquiry was set up to investigate alleged elder abuse during 2000–2001. After the two volumes report of the findings was published, awareness of elder abuse increased leading to changes in policy and legislation in South Africa. For this reason only articles published since 2000 were included .The researcher reviewed each of the 39 citations and abstracts that were retrieved. After this the full texts were retrieved and reviewed. A manual search of the reference list of all the included articles was done. All peer-reviewed articles/theses that were deemed to be elder abuse research or reviews in a South African population were included. Newspaper articles, case studies, government reports, textbook chapters, conference papers, and other publications that were not peer-reviewed were omitted.The initial search results resulted in a total of 39 papers; one additional study was added after manual search of the reference lists of the publications that were already included. Refer to Figure Two studies were excluded because they were done in Namibia and one study was published before 2000. Screening of the titles and abstracts excluded seven more studies, as they were found irrelevant to the review scope. The full texts of the remaining 20 articles were retrieved for final assessment. After applying the inclusion and exclusion criteria six more articles were excluded, because they were not original research or reviews. Fourteen articles were included.Ten articles were published in peer-reviewed journals and contained original data or reviews on elder abuse in South Africa. The publications of four research projects, where a thesis was written for master degree purposes, were also included. Most of the studies included used qualitative or review methods.There were only four studies with original research of a quantitative nature: the study by Bigala and Ayiga included cross-sectional data of 506 elderly persons ; Meel diThere have been several systematic reviews about the state of elder abuse globally. The majority of studies of elder abuse were conducted in North America, Europe, and Asia, with only two studies identified in Africa. Five of the most recent reviews of elder abuse research, done between 2011 and 2018, and one review that focused specifically on sexual violence against older people did not include any studies done in South Africa , 12, 13.The proportion of elderly in South Africa is on the increase with 8.1% of the population being over the age of 60-years. Despite this, the problem of elder abuse has not received much attention from researchers or policy makers. No national epidemiological studies about elder abuse in South Africa could be found .Only one study included recent data about the prevalence rates of elder abuse in a small local area and another study focused specifically on rates of sexual assault in elderly woman. From these studies it appears as if the rates of abuse are very high. Bigala and Ayiga found that 64.3% of men and 60.3% of women reported experiences of abuse in Mafikeng. Mafikeng is situated in the Northwest province of South Africa with an estimated population of 250,000. In this study it was found that men experienced more physical abuse and women more emotional, financial, and sexual abuse. In Mthatha, between 2007 and 2011, the average rate of rape among elderly women was 20.7/10 000 adult women per year , 10.Preliminary analysis of 3,402 calls over a 2-year period to a national toll-free service to report abuse showed that the biggest category of reported abuse was physical abuse, followed by financial abuse and problems with pensions. Two-thirds of the reported incidents took place in private homes and in half of the cases the victim was the caller .As found in the international literature, local research into elder abuse is hindered by the lack of a universal operational definition with a clear cut-off for what exactly constitutes abuse. The definitions used by organizations like Action on Elder Abuse South Africa, National Strategy on Elder abuse and Department of Social Development all vary slightly. It is also different from the definition as provided in the Older Persons Act 13, of 2006 where it is defined as “any conduct or lack of appropriate action, occurring within any relationship where there is an expectation of trust, which causes harm or distress or is likely to cause harm and distress to an older person.” It specifies the types of abuse as physical, sexual, psychological, and economic –17.Against the background of the historical disadvantages and the multicultural nature of the South African population, this definition is sometimes considered too narrow. There exist unique categories of abuse not usually found in developed countries. These include loss of respect for elders and systemic abuse, which refers to dehumanizing treatment at health clinics, pension pay points, and marginalization of older people by the government. There are also problems with allegations of witchcraft, mainly against elderly black women, and as a result of the accusations their property can be confiscated and they can be assaulted or even burnt. Another concerning tendency is particular violent forms of abuse, specifically rape of older women by sons or grandsons to extort pension money. These acts tend to be concealed and are often not seen as rape in the communities, because the abuse is perpetrated within the family , 17, 18.In addition to these challenges, South Africa had to deal with the effects of the HIV/AIDS epidemic as the country with the highest number of infected people in the world. During 2017 it was estimated that 7.06 million South Africans or 12.6% of the total population were HIV positive, with young, black females being most at risk. HIV/AIDS has not only changed the roles of older persons to being caregivers and providers for ill adult children or orphaned grandchildren, but has also traumatized them. They suffer from the effects of caregiving, the death of relatives who succumb to AIDS and the grief and isolation attached to the illness. Secondary to the illness or death of family members, entire households end up being dependent on the pensions of older people , 19, 20.The Older Persons Act came into effect in April 2010 and aims to maintain and protect the constitutional rights of all older persons and to facilitate accessible, equitable, and affordable services to older persons. The Act makes provision for mandatory reporting of suspected abuse by any citizen, not just by health care professionals, but the procedures for reporting remains cumbersome. The Department of Social Development also had to establish a register to keep track of criminals who have committed crimes against elder persons. This register is still not up and running. There is a lack of enforcement mechanisms for the various sets of rights conferred on older persons by the Act and law enforcement agencies often fail older victims who attempt to report abuse , 21–23.The majority of older South Africans are not in residential care and there is a critical shortage of proper facilities to care for the elderly. Most of the elderly live in rural areas and in communities with their families or on their own. The care of older persons is regarded as the responsibility of the family and the state has made it clear that its duty to provide care applies only in the case of frail older persons who have no family to care for them. The expectation that elderly should be cared for by the younger generations has in some cases been turned upside down because of rapid social change, urbanization, migration, and the high incidence of HIV/AIDS , 22.The main risk factors to become a victim of abuse are being female, presence of cognitive impairment, and being older than 74-years old. In the Mafikeng study factors that were associated with elder abuse included having no working children, being single or living in an elderly couple family, living in rural areas, having a poor self-perception of health and having a disability .Unemployment rates in South Africa are estimated at around 26.7%. Older people view poverty, unemployment and the subsequent use of alcohol and drugs as contributing factors to abuse. The breakdown of family structures, loss of respect for elders, beliefs in witchcraft, high crime rates, including domestic violence and socio-economic inequalities remaining after the apartheid system are also blamed , 22, 24.The experiences of the elderly and whether or not they experience abuse and neglect is largely influenced by their socio-economic circumstances. Old age is easier for some groups in the South African population, but more research is needed into the prevalence and risk factors for abuse in specific groups. Culture, political, economic, and social realities, together with negative societal attitudes toward older persons are exacerbating the vulnerability of the elderly to poverty, abuse, and violation of their human rights , 25.The extent of research done in the field of elder abuse in South Africa is very limited and the original research was done in small local areas in the country. The number of individuals included was small, with the focus on predominantly one racial, cultural, or socioeconomic group. This limits the generalizability of the research findings, even on a national level. No consistent definition of abuse or an elder abuse instrument that clearly defines a cut-off for definite elder abuse was used. Most of the reviews that were referred to included policy documents and other types of documentation that were not peer reviewed or were not original research.According to the articles that were reviewed with prevalence estimates, elder abuse seems to be very common and widespread in South Africa. The most vulnerable groups seem to be those living in rural areas of a lower socio-economic class and they tend to be older and frail. Health and health-allied professionals should consider routine screening for abuse in this population when the older person has contact with health services.The majority of the elderly are being cared for in communities and some very frail older persons are receiving care from untrained individuals, increasing their risk of becoming victims of abuse. This situation is exacerbated by the lack of trained health and social welfare personnel to supervise geriatric care and community welfare organizations . TraininThere are many barriers to the mandatory reporting requirements. Health professionals may be reluctant to report elder abuse and this reluctance should be addressed by streamlining of the reporting process and implementation of effective enforcement mechanisms after such reports are lodged. There is a legal obligation to report suspected abuse, but for health professionals the overriding concern must always be the safety of the patient and prevention of unnecessary suffering.It is crucial that nations take a multifaceted approach to ensure protection of older adults. For this to be done effectively, national longitudinal research about the prevalence, specific risk factors for elder abuse in different contexts and its consequences is needed. Research can be improved and made more generalizable by the use of a single universal operational and comprehensive definition of what constitutes abuse and neglect. Culturally sensitive tools to define and measure elder abuse, such as the screening tool developed by the South African Department of Health, Elder Abuse Screening Tool (EAST) should be validated and considered for use in future research.Older people should be informed about their rights and how to access support services. Community members and health professionals should be aware of the reporting requirements and processes to follow. Awareness campaigns can be done in the forms of community workshops and media campaigns, while government involvement should be encouraged. Research into elder abuse should be encouraged and results should be used to address gaps in policies, legal processes, and service delivery.Despite some unique categories and differences, elder abuse in South Africa shares similarities with all other countries. The elusive standardized operational definition and clear cut-off for elder abuse is a global problem and limits generalization and application of research findings. Collaborations between researchers, communities, governments, and different countries can improve future research efforts.Elder abuse occurs in every country and governments have a very important role to play in the care and protection of older citizens and should implement strategies that allow persons to age with security and dignity. This should include early recognition of elder abuse, effective reporting processes, adequately trained professionals and suitable care facilities. The problem of elder abuse cannot be properly solved if essential needs are not met. Opportunities should be created for older persons to participate in their societies and to alleviate poverty and its associated negative consequences of ill health and abuse. There should be coordinated efforts at the national level to preserve and protect the human rights of vulnerable aging populations and to prevent elder abuse in all its forms.The author confirms being the sole contributor of this work and has approved it for publication.The author declares that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Patient safety became the focus of attention of the World Health Organization (WHO), which in 2004 launched the World Alliance for Patient Safety , Medication errors are a relevant problem to face, in terms of patient damage and health systems sustainability, since worldwide their costs are estimated to reach 42 billion US dollars per year. The goal proposed by WHO is to reduce the level of serious and preventable drug-related harm by 50% within a 5-year period. One of the recommendations is the development of specific action programs to improve safety in situations where a drug can cause unintended harm, including health professionals' behavior and medication practices and systems  were excluded after reading their titles, abstracts and full texts . Data frThe methodological quality of the selected systematic reviews was assessed independently by two investigators who used the Assessing Methodological Quality of Systematic Reviews tool—AMSTAR , thus, in order to best address considerations about the process of implementation, for each one of the options we searched qualitative articles at the BVS Regional Portal. This step aimed to identify, preferably, strategies performed in Brazil, our context, and that could be relatable to other UMIC (Upper-Middle-Income Countries).Of the 1,191 systematic reviews identified, 40 were selected and analyzed in order to draw up the options provided . From thThirteen systematic reviews addressed the effectiveness of educational actions in preventing or reducing prescribing errors, of which six were deemed as having high methodological quality, three as moderate, and four of low quality.The following studies highlighted the positive effects produced by educational actions through different approaches: educational performance of pharmacists . When implementing health policy options, managers usually need to tackle several types of obstacles. Not only it is necessary to consider them, but also to find ways to overcome them, especially those related to cultural and social representations of health care users and workers. The following are some difficulties that may be encountered when implementing each of the options and issues that may give rise to iniquities, especially in Upper-Middle Income Countries.Implementing these interventions may aggravate iniquities when the prescriber does not participate in those activities, whatever the reasons, which may be a consequence of institutional disorganization, lack of personal motivation, or overvaluation of the knowledge they already have.In the literature, the barriers that must be overcome may be encountered both at the individual level , and at the collective level . In addition, difficulties may arise due to insufficient human resources or in complying with previously established guidelines , as well as actions to raise awareness about and encourage the use of these technologies by prescribers.The obstacles observed include a lack of rapid and simplified access to information by means of electronic systems in emergency situations  alone, does not produce significant results Silva, . Not shaFurther studies should be conducted on factors influencing prescribing and evaluating specific strategies (Davey et al., Pearson et al.  reportedThe use of the STOPP/START criteria remains incipient in health services, except in emergency services, and further studies are thus needed to assess this tool's efficacy in detecting potentially inappropriate prescriptions (Hill-Taylor et al., There are several options indicated in the scientific literature that are effective and safe to assist professionals in order to avoid or reduce medication prescribing errors in health services. Our evidence brief for policy present four options that may be useful to deal with this problem, although there is no recommendation on which one is the best. The decision to implement one or more options depends on the context where the decision makers are inserted.The options are not exclusive and can be used together, according to the local reality of implementation.When implementing these options, however, it should be taken into account that the number of studies is still incipient and confidence in the results could be improved with further research with high methodological quality.BA, RM, JB, and TT contributed with the design and conception of the study. BA and RM wrote the first draft of the manuscript. BA, RM, and TT participated in the study selection process. MB and TT contributed to the revision of the manuscript, read and approved the submitted version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


As stated in this book’s introduction, it is estimated that approximately 2.8 million people in the United States are living with prostate cancer: living with a diagnosis, undergoing treatment, or living in the posttreatment recovery stage. Using the estimate that about 4% of men in the United States are gay or bisexual, this means that about 100,000 gay or bisexual men have been diagnosed with prostate cancer. Another statistic cited in the introduction is the fact that 1 out of 6 gay and bisexual men in the United States will be diagnosed with prostate cancer sometime in their lifetime (p. 3).As a cancer that is tied so tightly to sexuality, it would be reasonable to assume that prostate cancer patient care and information would encompass a variety of sexual preferences and practices, as a way of being culturally competent and addressing patient needs. However, as this volume of essays and research studies shows, a major disparity exists in the quality of care and information received by gay and bisexual men who are living with prostate cancer.The book’s chapters are grouped in three broad sections. The first section provides an overview of the current research base regarding the experiences of gay and bisexual men with prostate cancer, both physically and emotionally. As described in several chapters throughout this collection, prostate cancer is a disease that affects not only the patient, but also the patient’s partner. Hetero-centric patient support has focused on the wife’s role in the patient’s care and recovery as the primary emotional support and sexual partner. Gay and bisexual men living with prostate cancer have different types of relationships to consider.Most of these early chapters discuss sexual identity and the patient’s place in a same-sex relationship or in the patient’s social network of friends and family. This section focuses on the importance of these nonbiologically based social networks and relationships in the treatment of and recovery from prostate cancer.The chapters in the second section deal with cancer care and support for this population during treatment and recovery. Some of the topics discussed include cancer treatment decision making, the effects of radiation therapy on sexual health, and experiences with sexual aids and other forms of sexual rehabilitation after treatment. The final chapter of this section notably discusses the development of Malecare, a gay, bisexual, and transgender prostate cancer support group.Because sexual practices and interests for gay and bisexual men will differ from those of heterosexual men, it is important to provide relevant advice and information to the patients and the people in their support networks. However, as described across a number of the chapters in the book, many gay and bisexual men do not come out to their health care providers. Many who do are faced with confused or even hostile reactions from physicians and others. For treatment and recovery to be fully successful, culturally appropriate therapies are necessary, and these chapters discuss effective, relevant treatments for gay and bisexual men living with prostate cancer.The final section, and perhaps the most accessible, provides firsthand accounts from gay and bisexual men of their own experiences with prostate cancer. These personal stories put the research findings from the other chapters into context. The authors recount their experiences in health care systems where providers often do not ask about sexual orientation and make assumptions that might not be appropriate for their patients. Several of these authors describe their proactive efforts to receive care that is responsive to their needs. However, the overall tone of these essays was one of optimism, as more providers become aware of the diverse needs of their patients.While gay and bisexual men are the primary subjects of the book, some chapters carefully redefine the subject base to include all non-heterosexual persons with prostate cancer. This redefinition allows discussion of transgender women, a small and often neglected part of prostate cancer demographics. Because their numbers are very small, the evidence base is lacking regarding their prognoses and experiences. However, there are enough instances of transgender women with prostate cancer to mention them and their needs, an important inclusion by the authors.A twelve-page glossary at the end defines many words and phrases used throughout the book, both those of a medical nature and those specific to LGBTQ+ culture and sexuality.Because of the multidisciplinary nature of this volume, it could be a useful addition to several types of health sciences library collections. It is certainly recommended for libraries seeking to build their LGBTQ+ health holdings, as well as libraries with strong collections in oncology or sexual health. It is also recommended for libraries serving psychology, counseling, or social work programs. While the overall tone of the book is somewhat academic, the firsthand accounts in the final chapters might also make it appropriate for consumer health collections in hospitals.Gregg A. Stevens, AHIPgregg.stevens@stonybrook.edu, http://orcid.org/0000-0003-4088-6742, Health Sciences Library, Stony Brook University, Stony Brook, NY,


The balance of expense and ease of use vs. specificity and sensitivity in diagnostic assays for helminth disease is an important consideration, with expense and ease often winning out in endemic areas where funds and sophisticated equipment may be scarce. In this review, we argue that molecular diagnostics, specifically new assays that have been developed with the aid of next-generation sequence data and robust bioinformatic tools, more than make up for their expense with the benefit of a clear and precise assessment of the situation on the ground. Elimination efforts associated with the London Declaration and the World Health Organization (WHO) 2020 Roadmap have resulted in areas of low disease incidence and reduced infection burdens. An accurate assessment of infection levels is critical for determining where and when the programs can be successfully ended. Thus, more sensitive assays are needed in locations where elimination efforts are approaching a successful conclusion. Although microscopy or more general PCR targets have a role to play, they can mislead and cause study results to be confounded. Hyper-specific qPCR assays enable a more definitive assessment of the situation in the field, as well as of shifting dynamics and emerging diseases. Parasitic worms impact the health and economic well-being of billions of people worldwide. Soil-transmitted helminths (STH) are a burden in the tropics and subtropics and contribute to an estimated 1.9 to 2.1 million disability-adjusted life years (DALYs) and US $7.5 billion to US $138.9 billion in loss of productivity . EffortsDiagnostic techniques need to be inexpensive, practical, and give consistent results across technicians and laboratories. Importantly, they must be accurate, sensitive, and easily interpreted. Microscopy has long been relied on as the standard for diagnosis of intestinal parasites, including soil transmitted helminths . SeveralTrichuris trichiura eggs are notoriously difficult to break open, and this impacts the sensitivity of molecular assays, but techniques are being developed and improved to the point where consistently good results are achievable , minisatellites (< 15 bp in arrays of 0.5–30 kb), and satellites  that are generally enriched within the centromeric, pericentromeric, and subtelomeric regions of the chromosome . Copy nuOther types of repetitive DNA include transposons and retrotransposons, which are dispersed throughout the genome. These include short interspersed nuclear elements (SINEs) which are 100 to 500 bases long, and long interspersed nuclear elements (LINEs) which are larger—6,000 or 7,000 bases long. These may also be useful for repeat-based assay design .The amount of repetitive DNA in any eukaryotic species is variable and can make up quite a large percentage of the genome. A recent study of parasitic worms revealed that both genome size and repeat content of the genomes range widely, with repeat elements forming up to 37% of the genomes in STH of interest Table 1.The value of repeats as diagnostic tools has been understood for some time but these sequences were more difficult to find in the pre-genomics era . Now, abDiagnostics give an estimate of the true prevalence of a disease, with the probability of correctly estimating the truth given by the sensitivity and species-specificity of the diagnostic. WHO guidelines for when to treat a community are informed by the prevalence of disease in that community, and are thus influenced by the sensitivity of the diagnostic used. A study modeling the probability of making the correct treatment decisions given WHO guidelines for treatment and varying the true prevalence and diagnostic sensitivity shows that there is a significant difference in outcome when more sensitive diagnostics are used . Medley The aforementioned study measured outcome by looking at DALYs and found that these were not as influenced by diagnostic sensitivity in low or high prevalence areas. However, there are other reasons to prefer more sensitive tests in low prevalence areas. As the goals of the WHO elimination programs are reached, there will be pressure to reallocate the funds spent on MDA to other programs. A well-defined threshold under which recrudescence will not occur is critical to preventing the reoccurrence of disease after the completion of MDA. Restarting such programs would be extremely difficult and expensive once they have ended. Modeling has shown that the threshold must be based on true prevalence , which chttps://github.com/JessicaGrant/RepeatTargetScripts). Primer/probe qPCR assays targeting sequences discovered using this technique have been shown to amplify as little as 20 ag of genomic DNA, or less than the amount of DNA found in a single egg  would have missed the infection. This highlights a risk of using extremely specific qPCR assays in the field if the precise parasite community is unknown. It also highlights that A. ceylanicum may be a much more common human pathogen than previously supposed. Here, the repeat-based, species-specific assays can be used to identify the true prevalence of various related parasite species.In a similar case, the same ITS-based primer set  was usedThailand . Since tic assay , as wellTrichuris trichiura (whipworm) detection by microscopy is assumed to be high, given the relatively distinct morphology of Trichuris eggs. However, there are several species of Trichuris, including some that infect companion or farm animals. Distinction between species of Trichuris relies on size differentiation, but there are overlaps in some species making misdiagnosis by microscopy possible. The most common species in humans is T. trichiura, but Trichuris suis, which commonly infects pigs, and Trichuris vulpis, usually found in dogs, have also been found infecting humans , which is funded at The Task Force for Global Health primarily by the Bill & Melinda Gates Foundation, by the UK aid from the British government, and by the United States Agency for International Development through its Neglected Tropical Diseases Program. In addition, this work was partially funded through a grant to the DeWorm3 Project, which is funded by a grant to the Natural History Museum from the Bill and Melinda Gates Foundation.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Repeated psychiatric readmissions are a particular challenge in the treatment of substance use disorders and are associated with substantial burden for patients and their associates and for healthcare providers. Factors affecting readmission rates are heterogeneous and need to be identified to better allocate resources. Within the Swiss healthcare system, such data on substance use disorder patients are largely missing. Understanding these factors might bear important implications for future healthcare planning. Thus here, we examine risk factors of inpatient readmission. We retrospectively analyzed all admissions to the hospital's department of addictive disorders in the year 2016. Patients included in the study were followed over a period of 1 year after discharge regarding readmissions to the clinic. Besides the demographic, social, and economic data, we extracted data concerning patient history, admission, and discharge as well as clinical data regarding type and number of substances abused and comorbid diagnoses. In order to describe severity of cases, we furthermore included the scores of the Health of the Nation Outcome Scale (HoNOS) at admission and at discharge as documented in the medical database. Of the 554 patients included in the study, 228 (41.2%) were readmitted within 12 months. Previous admissions, concomitant use of different substances, presence of psychosis or mania, and a higher severity score at discharge increased the likelihood of readmission. The odds for readmission were furthermore higher in patients not being married, living alone, and being unemployed. When all (bivariate) statistically significant factors are included into a logistic regression model, the previous number of admissions and the HoNOS clinical score at discharge significantly contributed to this model. Our findings stress that patients with higher symptom load at discharge are prone to be readmitted within 12 months. The same applies for patients with previous admissions. These findings suggest that the development of specific interventions to prevent premature discharge before satisfactory symptom remission, in particular in those patients with previous admissions in their patient history, might help to prevent readmissions. Substance use disorders (SUDs) are conditions in which the use of legal or illicit substances leads to significant impairment or distress . AccordiFrom a recent review on pre-discharge factors of readmission in general psychiatric patients, we know that the most consistent factor predicting readmission appears to be a previous hospitalization . With reMoreover, social factors such as being homeless or on health coverage through fee-for-service Medicaid in the US have been shown to be related to increased readmission rates . Other rHowever, the abovementioned findings are inconsistent. One reason for this inconsistency might be that some statistical models did not control for previous admissions, i.e., the variable most consistently found to be associated with readmission in psychiatric patients. On the other hand, the inconsistent findings might be explained by differences in the healthcare systems of the countries in which the studies were conducted. For example, Switzerland only has a very small proportion of patients with SUDs that are homeless or have no access to inpatient treatment compared to the US or other European countries.It is therefore important to identify those patients with SUDs at high risk of readmission to inpatient treatment and to better understand the factors that contribute to this risk.Factors that may affect readmission rates are manifold and can be divided into different categories. Specifically, factors at the patient level  can be differentiated from factors at the program level . In this study, we primarily focused on predicting factors at the patient level. As far as we are aware of, our study is the first to address this question in more detail on the basis of a larger sample of consecutively referred patients to a specialized SUD service followed over the period of 12 months.The Psychiatric Services Aargau (PDAG) are an academic teaching hospital of the University of Zurich, Switzerland, and provides a capacity of 331 inpatient treatment places for adults with acute or chronic psychiatric disorders of all kinds. The hospital provides inpatient treatment for approximately 700,000 inhabitants of the Canton of Aargau, Switzerland. The Department of Addictive Disorders of the PDAG is the only provider for acute psychiatric inpatient treatment for patients with SUDs in the canton. The department consists of three separate wards, of which one provides 11 places with a closed treatment setting. On this ward, another 11 patients can be treated in an open setting, and the other two wards provide additional 42 treatment places in an open setting.post hoc analysis of data. For every patient included in the study, a follow-up period of 1 year after the day of discharge was defined. We analyzed features of the index episode and the next readmission within this 1-year follow-up period.We performed a retrospective chart review using the electronical medical records from all patients that were discharged from the Department of Addictive Disorders within the period from January 2016 to December 2016. All patients with a diagnosis of the ICD category F10–F19 of mental and behavioral disorders due to psychoactive substance use were included into The study was approved by the responsible regional ethics committee (BASEC 2017-01533).We retrieved information on the following factors from the database of the PDAG:Demographic (age and gender), social , and economic (employment: employed vs. unemployed or on disability pension). We also extracted data concerning the patients' history (number of admissions), information on admission and discharge . We furthermore included clinical data regarding substance of abuse, number of SUDs as well as additional psychiatric diagnoses. The Health of the Nation Outcome Scale (HoNOS)  at admisn) and percentages (%) were reported for the two groups. In order to identify potential predictors, we calculated logistic regression models and the Wald test was used to test the coefficients. We first calculated odds ratios for each of the abovementioned variables separately with readmission (no readmission vs. readmission within 1 year) as the dependent variable. All factors/variables that showed a statistically significant effect were then included together in a logistic regression model. Significance level was fixed at p < 0.05.To analyze the data, all patients with SUDs were classified into two groups: patients with and without readmission within 1 year after discharge. For scaled variables (like HoNOS or length of stay), the means and standard deviations (SD) were calculated. For categorical variables , the numbers .n = 228) and not readmitted (n = 326) patients in Between January and December 2016, 566 patients were discharged from the Department of Addictive Disorders. Of these, 12 patients had to be excluded because they had no SUD diagnosis. The characteristics of the remaining 554 patients are reported separately for readmitted . Similarly, patients living alone and, even more so, patients living in institutions were more likely to be readmitted than patients living together with their family . Moreover, if patients were unemployed or on disability pension, the chance for readmission was elevated as compared to patients on employment . Age, gender, and education level did not show significant effects on the risk of readmission.The likelihood of readmission increased with the number of previous admissions .The length of stay did not show a significant effect. Moreover, involuntary admission in the index episode and type of discharge in the index episode did not significantly increase the risk of readmission.R2 = 0.199; Hosmer–Lemshow test: X2(8) = 8.255, p = 0.412).While the different substances used by the patients showed no effect on the readmission risk, the total number of SUDs was associated with a higher risk of readmission (OR = 1.222). A concomitant diagnosis of schizophrenic psychosis or bipolar mania increased the likelihood of readmission (OR = 1.856). And also with higher HoNOS scores at discharge the risk of readmission increased (OR = 1.064). HoNOS at admission did not show a statistical significant effect. When all statistically significant predictors are entered together in a logistic regression model, the number of "admissions" still revealed to be the factor most strongly associated with the risk of readmission  therefore may be left unidentified. In the present study, we only focused on factors at the patient level. Further research on the treatment programs is required in order to analyze predictors of readmission also at an institutional level.Regardless of these limitations, our study provides a rather long follow-up period of 1 year, which appears longer than in many other studies in the field. In addition to that, a generalization of our findings is possible because the referrals were consecutively included into our study.Some of our findings are in contrast to previous studies. For example, we could not confirm an influence of education on readmission. Furthermore, use of opioids or cocaine was, in our sample, not associated with a significantly higher risk of readmission in comparison to alcohol. And we found no increased risk of readmission for patients with SUD and depression or other comorbidities besides psychosis. These findings underline that variables that predict readmission in one country might not necessarily apply to the next. Our main findings regarding number of admissions and HoNOS extend previous studies from other countries and underline the need to prevent patients from premature discharge in spite of a high symptom load in order to prevent readmission. Longer periods of inpatient treatment may lead to less financial compensation, making it unattractive for institutions to retain patients in an inpatient setting. But the findings of our study indicate that a higher symptom load at discharge might, on the other hand, be associated with a significantly higher risk of readmission and, accordingly, may contribute to higher costs for the healthcare providers and the society. Therefore, especially in severely affected patients and patients with more than one previous admission, it appears to be mandatory to contrast the higher risk of readmission against the incentives of a shorter length of stay. Suitable and reliable outpatient programs for severely affected patients and patients with a history of more than one inpatient treatment might contribute to resolve that dilemma.Datasets will not be made available upon request due to ethical restrictions.The studies involving human participants were reviewed and approved by Ethikkommission Nordwest- und Zentralschweiz (EKNZ), Basel. Written informed consent for participation was not required for this study in accordance with the national legislation and the institutional requirements.VB and BH developed this study. BL, BH, and VB performed the statistical analyzes. VB, BL, ES, WK, PR and BH discussed the findings and contributed to the manuscript.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.