Studies suggest that the Patient-Centred Medical Home (PCMH) model of primary care is more effective than standard care for improving clinical outcomes in patients with chronic diseases (non-communicable diseases), but the strength of the evidence base is unclear. The aim of the proposed systematic review is to generate a current synthesis of relevant studies on the effectiveness of PCMH model of primary care versus standard care in chronic disease management.Electronic databases such as MEDLINE, CINAHL, Embase, Cochrane Library, and Scopus will be searched using predefined search terms for PCMH, primary care, and chronic diseases for articles published up to November 2018. Reference lists of included articles and relevant reviews will also be hand searched. This review will consider eligible randomised controlled trials and controlled trials against predetermined criteria including two or more principles of PCMH model endorsed by Australian Medical Association. Data extraction will be performed independently by two reviewers, and retrieved papers will be assessed for quality using JBI Critical Appraisal Tools. Where possible, quantitative data will be pooled in statistical meta-analysis using the R packages ‘Meta’ and ‘metafor’. Effect sizes will be expressed as odds ratio  and weighted mean differences (for continuous data) and their 95% confidence intervals will be calculated for meta-analysis; robustness will be explored using sensitivity analysis. Heterogeneity will be assessed narratively and statistically using the Q statistics and visualised using Baujat plots including subgroup or sensitivity analyses techniques where possible. Where statistical pooling is not possible, the findings will be presented narratively.The findings of the proposed systematic review will provide the highest level of evidence to date on the effectiveness of the PCMH model versus standard primary care in chronic disease management. We believe that our findings will inform patients, primary care providers, and public health administrators and policy-makers on the benefits and risks of PCMH model of care.PROSPERO CRD42018085378The online version of this article (10.1186/s13643-018-0887-2) contains supplementary material, which is available to authorized users. The health burden from non-communicable diseases including major depressive disorder, diabetes, stroke, ischaemic heart disease, chronic obstructive pulmonary disease (COPD), lung cancer, and musculoskeletal disorders has risen in recent decades . ConsequHealth care systems in high-income countries typically focus on the ‘single-disease framework’, where the delivery of primary care for the management of multimorbidity is often fragmented, lacking integration, and continuity of care . ParadoxThe patient-centred medical home (PCMH) care model, initially introduced as “medical home” by the American Academy of Paediatrics in 1967, has been considered to conceptually provide highest quality of primary care for patients with multimorbidity . AlthougGuidelines released by the Royal Australian College of General Practitioners (RACGP) include a vision of equitable access to high-quality health care based on the PCMH . SimilarThis protocol was developed with guidance from the Centre for Reviews and Dissemination’s (CRD) Guidance for undertaking reviews in health care and Preferred Reporting Items for Systematic review and Meta-Analysis Protocols (PRISMA-P) statement , 30 Add. This syWe selected specific inclusion and exclusion criteria using the Population, Interventions, Comparators, Outcomes, and Study designs (PICOS) framework (summarised in Table This review will consider adult populations (over 18 years of age) treated for one or more chronic disease in a primary care setting. We will use the Australian Institute of Health and Welfare (AIHW) definition of chronic diseases as a wide group of conditions, illnesses, and diseases that are characterised by long-lasting and persistent effects leading to potentially intense and severe health ramifications . AlthougIntegrated primary health care or MDT approachesThis review will include studies which satisfy the following criteria based on the principles of PCMH recommended by the AMA , 33:Inte2)Any one or more other following principles of PCMHi.Coordination of careCoordination of services within levels of the health care system  using efficient referral pathways between sites of care.ii.Data driven quality of careUse of technology in the development and implementation of care plans, shared decision-making, and for quality improvement auditing.iii.Long-term patient-provider relationshipPromotion of continuity of care through an ongoing partnership between patient, GP, and the MDT health care professionals towards the shared goal of providing high-quality patient-centred care.iv.Patient empowerment and patient engagementEducation to empower patients to actively participate in the development and self-management of their chronic disease. Patient values, preferences, and autonomy should always be considered in these.GP led integrated care or MDT approaches consisting of at least one other health care professional , ANDEligible studies must include a standard care comparison group by any definition.This review will consider studies that report clinically relevant outcomes which include, but are not limited to hospital outcomes , patient clinical outcomes , and economic outcomes .This review will consider RCTs and controlled trials using any alternate method of treatment group allocation. If adequate information from controlled trials is not available, cohort studies with a control group will be considered for inclusion.We will exclude studies where there is genuine uncertainty regarding meeting any of the eligibility criteria (e.g. the PCMH model), duplicate publications, and papers published in any language other than English. Reasons for exclusion of studies will be reported as supplementary information.A comprehensive literature search will be performed to identify published articles up to November 2018 through searching of electronic databases such as MEDLINE, CINAHL, Embase, Cochrane Library, and Scopus. A three-step search strategy will be undertaken in this review. Records retrieved from the electronic databases will be downloaded to Endnote X8 reference manager and screened independently by two researchers. Full text copies of potentially relevant articles will be reviewed against the eligibility criteria for inclusion. A flowchart of the selection process will be produced following the PRISMA guidelines . An initData extraction will be performed independently by two reviewers using Excel spreadsheet software  . ExtractThe methodological validity of the articles included for the review will be appraised independently by two reviewers using JBI Critical Appraisal Tools . DiscrepA quantitative synthesis, where possible, is planned to pool data from included studies. Results will be subjected to double data entry to ensure data quality and reduce the possibility of error. The results will be pooled using a random-effects meta-analysis with standardised mean differences for continuous data and odds ratios for binary data and their 95% confidence intervals will be calculated. Heterogeneity will be assessed narratively and statistically using the Q statistics and visualised using Baujat plots, including subgroup or sensitivity analyses techniques where possible. We will also explore subgroup analyses based on the different study designs or characteristics included in this review where possible. Where statistical pooling is not possible, the findings will be presented narratively. We will grade the body of evidence for recommendations following the approach proposed by the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) Working Group .The systematic review outlined in this protocol paper aims to identify, assess, and synthesise the best available evidence on the effectiveness of the PCMH model of primary care for chronic diseases management. We anticipate that the proposed systematic review will be the most comprehensive evidence summary to date and believe that the findings of our systematic review will provide the most conclusive evidence   on the eThe proposed review will provide reliable information on the benefits of the PCMH model such as improving quality of care, clinical outcomes, and reducing hospital and ED admissions , 19, 21.We anticipate that our findings will be useful to GPs and primary care providers also, which may lead to transformational organisational changes in their structures and practices. This may encourage primary care services to be efficient in better targeting of health services according to the needs of the local community . ProvideFinally, the proposed systematic review findings might help policy-makers and health ministries in understanding health and economic benefits associated with the PCMH model of care , 43. ThiIn summary, the proposed systematic review aims to address existing knowledge gaps by providing the highest level of evidence on the effectiveness of PCMH in chronic disease management. We expect that our findings will better inform patients, primary care providers, and policy makers on the benefits and risks associated with the PCMH model of care. In addition, the proposed systematic review may provide perspectives in achieving efficiency gains in health systems and future research opportunities.Additional file 1:PRISMA-P 2015 Checklist. (DOCX 34 kb)Additional file 2:Sample search strategy using MEDLINE. (DOCX 17 kb)Additional file 3:Data extraction form for experimental studies. (XLSX 10 kb)


OBJECTIVES/SPECIFIC AIMS: The proposed pilot study seek to enhance the network of CTSAs at Rockefeller University, NYU, ISMMS, and other community members to support translational workforce development of clinical research nurses and establish a standardized nurse-specific training curriculum in GCP for use within the CTSA network, in other research centers, and in nursing school curricula. This will be coupled with a rigorous evaluation study to test the impact of the training and a comprehensive dissemination plan to make the training available to all nurses and nursing students via modern e-learning method. Aim 1. To create an integrated network of local CTSAs and community partners to develop, validate, and refine a pilot e-learning GCP educational and training program and content and outcomes dissemination plan. It is vital to integrate the efforts of CTSA leaders, community partners, and nursing educators to develop a pilot e-learning nurse workforce training curriculum and the associated evaluation measures and assessment plan. Delphi methods will be employed, coupled with rigorous assessment of face validity, content validity, and item reliability. The resulting educational training program will then be used for an e-learning educational intervention study in CTSAs, other sites, and nursing schools. Aim 2. To test the effect of the pilot GCP education and evaluation program for practicing clinical research nurses (CRNs) within the collaborating CTSAs and community partners, we will perform a randomized controlled trial using a Solomon 4 group design. For the student nurse population, we will develop a randomized control trial using a Solomon 4 group design blocked on course section. As this is a pilot study, descriptive statistics and confidence intervals around parameter estimates will be constructed. In addition, inferential statistics will be calculated on primary outcome of interest (change scores in knowledge of GCP) and measures of heterogeneity of data, patterns of missing data, and reliability of evaluative tools will be analyzed. Aim 3. To implement a dissemination plan to reach both nurses practicing the CRN specialty within CTSAs and other community settings. We will disseminate the program to other CTSAs through the CTSA network communication resources. To broaden the reach to a population of nurses and student nurses with limited prior education or training in nurse-specific GCP competencies, but who provide care to research participants in nontraditional research settings, we will craft a novel set of dissemination methods, including the CITI Program electronic platform that can be accessed by nurses and nursing students across settings. In addition, dissemination will be at nursing education meetings and in nursing journals.METHODS/STUDY POPULATION: There are several components to this pilot program. The component that includes a research strategy is the testing of the effectiveness of the training and educational interventions on GCP knowledge and efficacy. Study cohort: Recruitment of study subjects will be in coordination with 3 CTSA collaborators and community partners for 2 samples: (1) nurses who provide care to clinical research participants across a variety of settings  and who are already trained according to current standard in GCP, (2) nursing students from the collaborative network of the 3 CTSAs, NYU School of Nursing has agreed to pilot test the introductory student module. The methodological approach will be a random assignment control trial Solomon 4 group design for practicing CRNs within the collaborating CTSAs and community partners. For student nurse population, the methodological approach will be a randomized-control trial Solomon 4 group design blocked on course section. Survey measures of CRN GCP knowledge and efficacy will be obtained pre and post educational intervention. RESULTS/ANTICIPATED RESULTS: Aim 1. Expected outcomes are pilot e-learning nurse workforce training modules curriculum, and evaluation measures and plan appropriate for CTSAs, community sites, and nursing schools. Specifically, 14 modules (averaging 30 minutes each) for practicing CRNs, and one 45 minute module for nursing students. The significance of these findings will provide a framework for the e-learning educational intervention study. CITI Program is enthusiastic about the module development and refinement and will provide direction for consistency in formatting with current CITI Program modules, set-up of learner groups for comparison, and evaluative measures such as completion data and scoring. Aim 2. Expected outcomes are an effective pilot educational intervention for practicing nurses and students and valid and reliable evaluation tools and plan that can be generalized to the larger CRN and nursing community. Aim 3. Expected outcomes are an enhanced CTSA dissemination plan that includes non-CTSA resources and reaches non-CTSA employed nurses and nursing students. DISCUSSION/SIGNIFICANCE OF IMPACT: The expected outcomes of this pilot study are: (1) an enduring GCP education that can be continually updated and training structure for CRNs, and nurses and nursing students throughout the United States; (2) a reproducible effective standardized basic nurse-specific GCP curriculum for dissemination; (3) assessment tools to evaluate programmatic success, nurse and nursing student knowledge and efficacy on nurse-specific GCP; (4) and a CTSA dissemination plan that to reach non-CTSA nurses and nursing students. Our ultimate goal is the development of a translational workforce educated and competent in GCP at CTSA sites, at non-CTSA sites, and in nursing schools so as to improve the quality of clinical research.


This realist review was conducted to understand how stigma is reduced in relation to HIV test uptake in low- and middle-income countries (LMICs).A systematic search of eight databases resulted in 34 articles considered for synthesis. Data synthesis was guided by a preliminary programme theory and included coding the meaning units to develop themes or intervention pathways that corresponded to context-mechanism-outcome configurations.We found that the interventions produced an effect through two pathways: (a) knowledge leads to changes in stigmatizing attitudes and increases in HIV test uptake and (b) knowledge and attitudes lead to changes in stigmatizing behaviours and lead to HIV test uptake. We also found one competing pathway that illustrated the direct impact of knowledge on HIV test uptake without changing stigmatizing attitudes and behaviour. The identified pathways were found to be influenced by some structural factors , community factors  and target-population characteristics .The pathways and underlying mechanisms support the adaptation of intervention strategies in terms of social context and the target population in LMICs. According to the United Nations Programme on HIV/AIDS (UNAIDS), there are approximately 37 million people worldwide living with HIV and almost 95% of people living with HIV (PLWH) reside in low- and middle-income countries . Sub-SahThe Joint United Nations Programme on HIV/AIDS defined HIV stigma as a process of devaluation of people either living with or associated with HIV infection . Stigma Several interventions to reduce HIV stigma have been developed and evaluated for their impacts on HIV test uptake. Some interventions have context-specific effects . For exaStigma reduction interventions are complex. These interventions have multiple components: partly individual-related and partly resource-related . The intAlthough individual behaviours and choices cannot be fully predicted, public health researchers can identify non-linear semi-predictable patterns of choice-making that occur under certain circumstances following an intervention. There is evidence showing that interventions have been effective in reducing stigma and increasing HIV test uptake; however relatively little is known on how, why, for whom and in which circumstances particular stigma reduction interventions work , 10 .This review aims to address whether and how HIV stigma can be reduced to maximize public health benefits via increasing HIV test uptake in LMICs. Especially in LMICs, low income along with illiteracy and traditional beliefs may influence the association between stigma reduction and HIV test uptake . MoreoveThe aim was to develop programme theory to uncover the mechanisms operating in stigma reduction interventions to increase HIV test uptake in particular contexts. A programme theory provides plausible explanations of why certain interventions work or do not work in certain circumstances . ConsequA realist perspective was chosen because it allows for the evaluation of complex social interventions . The reaA middle range theory is understood as “theory that lies between the minor but necessary working hypotheses … and the all-inclusive systematic efforts to develop a unified theory that will explain all the observed uniformities of social behaviour, social organization and social change” . Pawson This realist review was informed by a scoping review of empirical and grey literature on stigma reduction interventions to develop a preliminary programme theory  Does stigma reduction lead to HIV test uptake? (2) What are the pathways leading to HIV test uptake?To bring together different sources of evidence that support, refine, or refute our preliminary programme theory, we performed a systematic search in the following eight electronic databases: PubMed, Excerpta Medica Database (EMBASE), POPLINE, PsycINFO, Sociological Abstracts, Web of Science, Scopus and the Cumulative Index to Nursing and Allied Health Literature (CINAHL). We also performed an opportunistic purposeful searching process in ‘Google scholar’, 3ie database, trail registers from Campbell International Development Coordinating Group and the databases of two international organizations, namely the World Health Organization (WHO) and UNAIDS to enhance the possibility of identifying ‘grey’ literature . OpportuWe screened the articles in two phases. In the first phase, we included the articles based on the following core inclusion criteria: (a) dealt with HIV-related interventions that addressed causes of HIV stigma or included intervention components to reduce HIV stigma; (b) based in the low- or middle-income countries; (c) quantitative, qualitative or mixed-method studies, or programme reports and policy documents that described various forms of stigma or compared CMO configurations between different stigma reduction intervention strategies; (d) written in English; and (e) the outcome was related to HIV test uptake or for non-quantitative studies, the impact of stigma on HIV-test uptake was featured. The papers that were published until the year 2016 were considered for inclusion. Two independent reviewers screened the titles, abstracts and keywords of the identified documents.In the second phase, the abstracts from the first phase were checked specifically against any one of the following three criteria: (a) whether the abstract described the association between stigma reduction and HIV test uptake, (b) whether the abstract referred to behaviour change relating to stigma reduction and HIV test uptake, and (c) whether the abstract described the social contextual factors influencing stigma reduction and its association with HIV test uptake.Abstracts were coded as ‘Yes’ if any of the three-inclusion criteria were satisfied, and ‘No’ if none of the criteria were met. After the screening of abstracts for the second time, the full-text of articles were retrieved and evaluated by two independent reviewers to ensure that one or more of our inclusion criteria were met. Disagreements about articles to be included and excluded were resolved through consensus between the reviewers. Documents were included in the review based on relevance, that is, the extent to which they informed the development of the theoretical framework or clarified the CMO configurations .For each included article, data were extracted independently by two researchers based on a data extraction tool. The contents of the preliminary programme theory were embedded in the data extraction form, and this provided a template to interrogate ‘what works, for whom, in what circumstances’. To test the usability and functionality of the data extraction form, the tool was pretested on three purposefully selected articles . The eviTo assess the quality of primary studies, the Mixed Methods Appraisal Tool (MMAT)-Version 2011  was used. MMAT is one of the few tools that appraises the quality of diverse study designs  and provIn this review, all the quantitative and qualitative data were analysed narratively. First, the data extracted from each study using the data extraction tool were summarized and organized in one evidence table , 15 interventions reported increases in HIV testing uptake, 8 reported reduction in stigma but did not report effectiveness in terms of HIV test uptake, 4 reported increases in self-efficacy or intentions to test and 3 reported interventions being ineffective to reduce stigma and increase HIV testing uptake.Our synthesis of all selected articles explained how stigma reduction interventions were implemented in relation to the opportunities or challenges provided by the contextual forces to increase HIV test uptake see Fig. . The synThe awareness raising strategy included HIV-specific fact-based written or verbal information, communication, and education as major components. This strategy was aimed at increasing knowledge, and changing attitude and behaviours. The awareness raising components in the interventions were: radio messages, printed mass media, interpersonal communication, films, health education programmes, role plays, group discussions, HIV advocate testimonies, presentations, workshops, questions and answers, mobile phone messaging, training, motivational interviews and counselling. All the interventions included in this review had the awareness raising strategy.The health service provision strategy included providing HIV-related services for the betterment of PLWH and the prevention of HIV infection in the community. This strategy reduced barriers related to health service access and logistics to increase HIV test uptake. The health services that were provided in the interventions were: anti-retroviral therapy (ART), routine health test without an informed consent , availability of anti-retroviral drugs to mothers and their newborns, safe childbirth, infant feeding counselling, voluntary counselling and testing (VCT), mobile VCT, home-based VCT, family-based VCT, community VCT and other reproductive health services. Altogether, 18 interventions provided any of these health services, and 15 of them provided VCT services.The community mobilization strategy involved local counsellors at the local community-level to enhance community organizing initiatives to raise awareness, change behaviours and provide health service to the community people. The local counsellors were traditional healers, youth counsellors, community health workers, local community leader or local facilitators. In the interventions, the mobilization of local counsellors was performed in the following activities: to organize community meetings on benefits of ART, to provide general information about HIV and HIV testing, to provide training to community leaders on ART and VCT, to work as a member of a community group that engages people in raising awareness of HIV, to perform HIV counselling and testing and to refer to the health clinic for standard testing and care. Altogether, 13 interventions had the community mobilizing strategy.The regulatory law strategy included incorporating HIV-related legislation to protect and respect the human rights of PLWH. None of the interventions included in this review were based on regulatory law strategy. Only one intervention was based on developing policies related to confidentiality and respect of the rights of PLWH and formation of a hospital steering committee to oversee the quality of care. This intervention was implemented only in four hospitals of Vietnam, targeting the health workers .The service provision strategy included providing social and psychological support to PLWH through teaching coping skills, directly contacting people associated with HIV and the friends or neighbours of PLWH and involving them in community development initiatives or health care and providing incentives or material support to the community people to access HIV-related services. Altogether, 7 interventions had the support provision strategy.In total, 23 intervention studies had combined more than one strategy. Among the 23 combination interventions, 15 reported increases in knowledge and attitude leading to HIV testing uptake. A total of 8 combination interventions integrated awareness raising, health service provision and community mobilization strategies. Unlike the 23 combination interventions, the remaining 7 singular interventions had only the awareness raising strategy. From these 7 studies, 5 reported HIV testing uptake as an outcome, and 3 of the 5 studies reported increases in HIV test uptake via increasing knowledge and changing attitude , 33, 37.Our synthesis of the evidence found six different mechanisms that were operating in stigma reduction interventions in relation to HIV test uptake, which were interlinked in three dominant pathways  to trigger attitudinal mechanisms and increase HIV testing uptake. The attitudinal mechanisms triggered by knowledge were reduced fear  and reduced shame . Among the 22 intervention studies reporting increases in HIV test uptake, 11 of them , 37–42 r“The local NGOs … visit once a month. They ask questions about my health.. . whether we are well or not, whether I take medicine regularly or not. I tell them that I take medicine every day. Home-based counselling and testing team also advises on the prevention of HIV transmission, including condom use”.Increases in knowledge were found to be the most common element to increase HIV test uptake in all the interventions. Altogether, 4 combination interventions  having awareness raising, community mobilizing and health service provision strategies were found to follow ‘Pathway 1’ to increase HIV test uptake , 38, 41., both interventions were complemented by national HIV testing programmes . In Africa, the HIV-related health care system (C), via increasing people’s access to health care and providing HIV prevention messages, has been independently changing community knowledge (M1) and attitudes (M2), and normalizing HIV testing uptake  [Two interventions based on the awareness raising strategy noted a positive association between the programme exposure and knowledge, reduced stigma and increases in self-efficacy or intentions to test in Botswana and Malawi , 33. Bot as ‘O’) .Interventions promoting home-based testing and counselling in several African countries ensured confidentiality in relation to testing and keeping the HIV status a secret which reduced people’s fear of unwanted disclosure (M2) and led to an increased level of participation in HIV testing services (O) , 27, 41.Laws that promote mandatory reporting of HIV information (C) could lead to exacerbating fear of unwanted disclosure of HIV status. Working in South Africa, Weighs et al. reported that, in a workplace where HIV is stigmatized, an intervention that provided support via providing incentives for HIV testing was reported effective to increase knowledge, reduce fear and increase HIV testing uptake (Pathway 1) . People In South Africa, an intervention based on mobilizing local female counsellors ensured increased communication across different generations (M1), reduced shame (M3) for women to discuss sexual and HIV testing matters, and increased family support for those who tested positive . Young gPathway 2 indicates the role of behavioural mechanisms to reduce discriminations among PLWH and consequently, increase HIV test uptake among at-risk or vulnerable populations. Seven interventions were found to follow Pathway 2 , 48–50. Two interventions that mobilized traditional healers were effective in changing community misconceptions (M1), reducing the perceived threat of HIV (M2), reducing the tendencies to blame (M4) and excluding PLWH (M5) in South Africa. Consequently, these interventions increased HIV test uptake among at risk population groups and the general population (O) , 48.Roura et al. (2009) and Moshabela et al. (2016) reported that, in some African communities, people believed that a wide array of diseases, including HIV, was caused by witches as a consequence of jealousy or revenge , 44. BecIn the past, the Sukuma called it “Kondela.” A person slims and looks like s/he is HIV positive, but s/he is not. It’s a disease similar to AIDS caused by medicines of the witches. It is often used if you quarrel with someone... if s/he has got that medicine s/he bewitches you.A participant from Tanzania (2008) put it this way ,In the “The project encouraged PLWH to become involved in their community. In the intervention village, two previously undisclosed PLWH joined the project and disclosed their status to other villagers and were welcomed into the community project.”All four intervention studies that specifically targeted health care workers through awareness raising , 50, 51 By contrast, the anti-homosexuality legislation in Uganda punished health care providers and families of MSM if they offered help and support of any kind, including HIV testing. This legislation reinforced a homophobic environment in the health care system and broader community (C), and lead to fear and discrimination . Based oOnly two interventions implicated the mechanism of increased interaction with PLWH. For instance, in an intervention implemented in Thailand (2007), community leaders, youth volunteers and PLWH were involved together in identifying community needs, mobilizing community resources, generating additional income, and disseminating HIV/AIDS information in the community . The intFour intervention studies reported increases in HIV test uptake due to the influence of knowledge but without any concomitant changes in stigmatizing attitudes and behaviours , 52, 53.In addition, one of these interventions was delivered in Kenya and reported changes in stigmatizing attitudes among community leaders (Pathway 2) but not among community members . The incSince the beginning of the epidemic, the majority of HIV prevention interventions have been based on awareness raising strategies . InitialSeveral behaviour-change models, such as the Knowledge-Attitude-Behaviour model and the Health Belief model, stipulate specific constructs and their relationships on how knowledge leads to changes in stigmatizing attitudes and behaviours . These mOur review identifies some inhibiting pathways that influence the process of stigma reduction and HIV test uptake. The pathways, such as (a) anti-homosexuality laws leading to the creation of a homophobic environment at health care facilities, (b) traditional beliefs and practices about the disease aetiology leading to blame of PLWH, and (c) gender inequality that increases the feeling of shame among women while discussing HIV testing with their partner, increase stigmatizing attitudes and discourage people to test for HIV. Our review makes it clear why, how and for whom an awareness raising strategy should be complemented by other intervention strategies to change stigmatizing attitudes and behaviours, and consequently, increase HIV test uptake. Based on our programme theory, we propose the following points to be taken into account while designing and implementing an intervention to reduce stigma and increase HIV test uptake.First, the interventions that are aimed at increasing HIV test uptake among at-risk or vulnerable populations should always take contextual factors into account. For instance, unless equal rights for MSM and the transgender population are ensured by law, stigma reduction interventions may not be effective to increase the participation of these specific population groups in HIV prevention. In this review, policies, such as anti-homosexuality laws and mandatory reporting of HIV test results, were found to create a homophobic environment with the health care system and broader community. Thus, policies, such as legal and social recognition of same-sex relationships or marriage and protection of sexual minority people from discrimination, should be implemented along with stigma reduction interventions to reduce stigma and increase HIV test uptake among the vulnerable and hard-to-reach population groups , 56.Second, to increase the access of at-risk or vulnerable populations to HIV test uptake, it is important that the interventions followed Pathway 2 to trigger both attitudinal and behavioural mechanisms. Combination interventions having active community mobilizing strategies were more effective to reduce stigmatizing attitudes and behaviours and to increase HIV test uptake among at risk and vulnerable populations. The most consistently successful combination of strategies was awareness raising, health service provision and community mobilization strategies. Thus, our findings strongly support the concept of combination prevention, including biomedical , behavioural  and structural intervention strategies , being more effective than individual prevention strategies .Third, within the combination prevention approach, involving PLWH in providing health care was found to be promising to reduce discrimination. Involving PLWH in health care was found to have two major advantages. First, these PLWH directly benefitted from health care. Second, the networks initiated by these PLWH and vulnerable populations compared with the networks initiated by the HIV-negative general population were noted to be more effective to reduce fear, increase interaction of PLWH with other people and increase HIV test uptake . Given tFourth, extending HIV testing uptake and coverage to underserved and hard-to-reach populations that do not necessarily access an existing health care service can be challenging. These populations are more likely to fear identification by being specifically targeted by HIV-related health services , 39. OurLast, the difference in stigma experiences and HIV test uptake between communities could partly be explained due to the difference in socio-economic status and partly due to the difference in health care access . TherefoStangl et al. (2013), in their review, have noted that the number, geography and complexity of stigma reduction interventions have expanded considerably, and, especially, a very high percentage of studies that showed reductions in stigma were of high quality . HoweverA key limitation of this realist review is that we were very specific to include only studies with stigma reduction components and published in English. We also did not attempt to perform an independent search for national-level grey literature in the websites of Governmental and non-governmental organizations. As a result, our review may have missed uncovering some other contextual factors and mechanisms. For example, Figures Despite these limitations, the use of a realist review is increasingly relevant in view of the contextualization of the issues, i.e., HIV-related stigma, implementation of interventions in different settings and contexts, as well as the psychological core constructs that render such interventions effective, in particular in LMICs. The scope of the review was broad, and not limited to one region , which added value in trying to achieve a saturation point in the number of ideas presented in the primary studies. There were 21 intervention studies that come from Sub-Saharan Africa and the studies that come from outside Sub-Saharan Africa also validated what have been learned from the studies conducted in Africa.In addition, we included and synthesized all types of studies  providing information about interventions, contexts, mechanisms and outcomes, surrounding stigma reduction and HIV test uptake. In this way, the review of evidence brought together a comprehensive perspective in terms of interventions and populations to the analysis and synthesis. In light of implementation research, there is a great need to better understand the general mechanisms that make stigma reduction interventions effective, and subsequently to collect evidence that goes beyond the typical experimental designs, which are not always feasible due to the complexity of interventions and the contexts in which they are implemented. The programme theory can be transferable to other communities and across diverse populations.The refined programme theory resulting from the realist review clarified why, how and under what circumstances interventions having singular or combination strategies are effective across different population groups. We found that these interventions produce an effect through two major pathways: (a) knowledge leads to changes in stigmatizing attitudes and increases in HIV test uptake, and (b) knowledge and attitude lead to changes in stigmatizing behaviours and consequently lead to HIV test uptake. In addition, this programme theory supports the adaptation of intervention strategies in terms of the socio-structural and cultural context and the population being targeted to reduce stigma and increase HIV test uptake in LMICs.


An examination on the perception, use, quality, accessibility and health risks of urban green and blue spaces is explored, alongside the availability of novel UGS and greenery-related approaches that investigate compact city design and planning for health and wellbeing. The amount of ‘green’ and relating UGS availability in cities indicates vital knowledge modern compact cities must consider.The modern compact city is identified as a high-density and mixed-use pattern. Its features are believed to contribute to a form of functional urban design that supports sustainability and, restresses, the importance of ecosystem services. Urban green space (UGS) plays a vital role in the design and impact on how compact cities have developed and triggered a scientific discord on the amount of greenery individuals require and to what extent contemporary approaches address the question. Research points to at least 9 m At present, cities are facing a number of environmental issues which influence the wellbeing and livelihood of millions worldwide. The consequences of urban sprawl have resulted in pollution, consumption of resources and energy and various types of dumping grounds . UrbanisThe compact city is identified as a high-density and mixed-use pattern which leaves space for the countryside, husbandry, nature and recreation. It includes a well-ordered distinction between the city and countryside  in physical appearance and land use functions to city-dwellers . This tyLocal authorities, increasingly, are in search of new, adaptive and flexible forms of urban gardening, characterised by high accessibility and hybrid functions . As a reWith the maturation of modern compact cities, urban green and blue space (UGBS) inquiries has become an integral part of urban green infrastructure (UGI) ; nonetheIn terms of the ecological quality of UGBS, the natural attributes of green space comprise of plant and animal diversity and abundance, flower density and tree canopy cover . Blue spBorrelia infected ticks [Additionally, people using UGBS could potentially come into contact with ed ticks . Withouted ticks ,27. Poored ticks   linkages between sustainable cities and better health, (2) core health indicators to monitor progress and identify success, (3) expanding indicators values , (4) adding value to health indicators and (5) feasibility of data reporting via cross-cutting issues . In retrospect to the amount of greenery and relating UGS availability in cities and urban areas we delineate a linkage between the World Health Organization’s UGS values with a reduced amount of social and environmental discontent [UGS availability, to date, historically relates to the chronology of events and activities that have occurred and decisions that have been formulated over the past few centuries; from a historical perspective, urban complexities have spotlighted a number of key indicators that have propelled improvements in human health, wellbeing and socio-ecological interactions within urban environments  . The Worscontent ,38,39,402 of UGS is available per inhabitant and virtually all its residential zones lie within a 300 m radius from public green space [An example of an ideal compact city is Ljubljana, Slovenia, awarded the 2016 European Green Capital, in which almost 560 men space . Over then space . At presCorrespondingly, Badiu et al.  maintainUGI and nature-based solutions are terms that are frequently applied interchangeably; they both integrate natural systems with build systems and are often reported as having a key role in achieving a future-oriented compact city framework—both for liveability and sustainability ,46. The Another example is Chicago, due to a billion-dollar investment since 2001, in which a wide range of projects, including the creation of new gardens and natural areas like Millennium Park and Palmisano Nature Park  have revamped the greenery and UGS city-wide . ConversUsing a combination of approaches and information  Best Practices Guidelines, UNESCO  Man and Biosphere Programme (MAB) and healing garden design approach ,56,57,58For example, the IUCN Best Practices Guidelines help to infuse nature into the built environment and break down the cultural barriers between ‘nature’ and ‘urban.’ According to these guidelines, there are three different ways of incorporating nature into the larger urban picture, this can be done via: (1) comprehensive, interdisciplinary scientific studies; (2) comprehensive local biodiversity strategies ; and (3) region-wide coalitions  . The ecoDogse  is descrFuture compact cities should also consider food insecurity and hunger. To this end, edible green infrastructure is a novel approach for the design of “edible cities” that have the potential to improve resilience and quality of life in cities as well as prevent food insecurity. Edible green infrastructure is a sustainable planned network of edible food components and structures within the urban ecosystem which are managed and designed to provide primarily provisioning ecosystem services. Typologies are based upon one macro category  as well as eight sub-classifications: (1) edible urban forests and edible urban greening, (2) edible forest gardens, (3) historic gardens and parks and botanic gardens, (4) school gardens, (5) allotment gardens and community gardens, (6) domestic and home gardens, (7) edible green roofs and vegetable rain gardens and (8) edible green walls and facades . A new concept of vertical forests is gaining popularity as it promotes the coexistence of architecture and nature in urban areas ,61. ReceAgain, the Asia-Pacific region has developed a notable project that is under development this year Tengah, Singapore; it is the first “Forest Town” that is fully integrated with its surrounding ecosystem with greenery formations as the main structural foundation of the town. Tengah will offer 42,000 residential dwelling units within five distinct districts: (1) Garden District, (2) Park District, (3) Brickland District, (4) Forest Hill and (5) Plantation District . The key attraction will be an approximately 100 meter-wide forest corridor which will provide ample space for residents to enjoy nature and relating nature-based services. A large central park will serve as the ‘green lung’ for Tengah. The park will be integrated with ponds and canals, providing lush greenery and recreational promenades .Another novel concept is the healing garden design approach used by Lau and Yang  in whichBy achieving these benchmarks, UGS site-specific performance in collaboration with the maintenance, support and enhancement of natural systems has proven to be an emerging indicator-based approach for the design and planning of compact cities. Well planned, maintained and designed compact cities have the potential to be both an environmentally sustainable and a liveable option . HoweverRecently, South et al.  found thProvisional designs of modern compact cities reported positive integration of UGS due to socio-perception and -behavioural attributes by green space users ,82. MuchCities can be compact as well as ‘green,’ with meticulous attention paid to every aspect of the urban greening complex . Urban p


The widespread application of technologies such as electronic health record systems, mobile health apps, and telemedicine platforms, has made it easy for health care providers to collect relevant data and deliver health care regimens. While efficacious, these new technologies also pose serious security and privacy challenges.The training program described here aims at preparing well-informed health information security and privacy professionals with enhanced course materials and various approaches.A new educational track has been built within a health informatics graduate program. Several existing graduate courses have been enhanced with new security and privacy modules. New labs and seminars have been created, and students are being encouraged to participate in research projects and obtain real-world experience from industry partners. Students in this track receive both theoretical education and hands-on practice. Evaluations have been performed on this new track by conducting multiple surveys on a sample of students.We have succeeded in creating a new security track and developing a pertinent curriculum. The newly created security materials have been implemented in multiple courses. Our evaluation indicated that students (N=72) believed that receiving security and privacy training was important for health professionals, the provided security contents were interesting, and having the enhanced security and privacy training in this program was beneficial for their future career.The security and privacy education for health information professionals in this new security track has been significantly enhanced. In most current health informatics, medical informatics, nursing informatics, and health information management (HI-MI-NI-HIM) education programs, there is either no dedicated security and privacy class or only one available course . At the Currently, the discussion on security and privacy issues continues in a variety of health care areas -6, especAccording to the Office of the National Coordinator for Health Information Technology data brief released in 2016, 96% of hospitals in the United States possess certified EHR technology. Likewise, 84% of hospitals had adopted at least a basic EHR system with clinician notes in 2015, which is a 9-fold increase since 2008 ,8. In laThe widespread adoption of new technologies such as mHealth apps and telemedicine systems makes security and privacy issues in health care more challenging and urgent since patients can easily share the confidential health data they receive from health care providers without knowing the security risks.The cloud and health social networks, an emerging new frontier for health care delivery, pose new challenges in security and privacy as well. Currently, there are many social media tools available for patients and health care professionals, such as social networking platforms , blogs, wikis, and photo and video sharing sites . Patients use Twitter to obtain knowledge and exchange ideas and use Facebook to obtain social support, while health care professionals use LinkedIn and Twitter to communicate with colleagues and identify potential jobs . The socHealth care professionals are responsible for educating patients regarding the safe and ethical sharing of personal health records. Furthermore, health care professionals must properly handle all types of sensitive health records, such as personal genomic information, EHR data, and data collected with mobile apps or other various trackers and wearable sensors. In other words, the changing face of health IT and health care information management requires that we enhance the security and privacy education offered to health care professionals, especially to students in HI-MI-NI-HIM programs.There are 3 typical approaches in enhancing security and privacy education in HI-MI-NI-HIM programs: (1) cross-listing existing security and privacy courses offered by computer science or information science departments, (2) adding a security and privacy course to the curriculum, or (3) addressing security and privacy issues in relevant courses. In the first approach, students in HI-MI-NI-HIM programs are required to have a solid background in computer science topics such as computer programming and computer networks. These prerequisites make the security and privacy courses inaccessible for many HI-MI-NI-HIM students. In the second approach, the major challenge for students is the connection between security and privacy theory and their application in health science. A single course can be used to introduce security and privacy theories but students do not have much chance to know the application of those theories in health care practice and health data management. The third approach is the opposite of the second approach. When instructors discuss specific health IT systems or health data management, they can describe the relevant security and privacy challenges; however, the instructors would not be able to go into the details of these challenges, the fundamental security and privacy theories behind those challenges, and the desired solutions.In response to this current situation, a new information security and privacy track in a Health Information Systems (HIS) graduate program has been created in the Department of Health Information Management (HIM) in collaboration with the Department of Informatics and Networked Systems (INS) at the University of Pittsburgh (Pitt) with the goal of producing highly desired, well-trained security and privacy professionals in the domain of health care. Instead of simply modifying the curriculum by cross-listing a number of existing security and privacy courses or trying to cover every aspect of security and privacy in a single course, a number of significant curriculum changes have been made. For example, courses from INS were modified and introduced in this new track. Multiple existing courses have been enhanced with security and privacy contents. New labs, seminars, research projects, and internship activities have also been developed and offered to students. It is expected that this new track will enhance the security and privacy training to students in this graduate program.The courses in the HIS graduate program are classified by type as Health Informatics and Foundation, Health Management, or elective courses/thesis option. Of the 15 available Health Informatics and Foundation courses, students are required to take 10; of the 5 Health Management courses, they must take 2. For their remaining credits, students are allowed to take 2 additional electives or choose the thesis option. Students in the thesis option take 2 courses: Graduate Research Proposal and Graduate Research. Here, students obtain course credits by attending seminars and conducting research under the guide of a project mentor.In developing the new security and privacy track, we introduced 2 required courses and 2 elective courses in the Health Informatics and Foundation category, offered in Pitt’s INS department. Required are Introduction to Security and Privacy (INFSCI 2150) and Security in E-Commerce (INFSCI 2731); Security Management and Computer Forensics (INFSCI 2621) and Developing Secure Systems (INFSCI 2620) are elective. These courses were chosen because they had rich contents in security and privacy, including both theoretical foundations (INFSCI 2150) and practical applications  in various fields. In addition, these 4 courses only required students to have general knowledge in computer systems and computer programming, which is also the prerequisite of our HIS graduate program. They did not expect students to have extensive knowledge in computer networks or cryptography. The instructors of these 4 courses have worked closely with faculty members in the HIS graduate program to create examples and case studies in these courses. The purpose was to contextualize these courses with current issues from the health care domain so that HIS students can gain an understanding of the most relevant security and privacy principles and technologies in the context of health care. For instance, INS instructors started to discuss Health Insurance Portability and Accountability Act (HIPAA) regulations and their impact to risk management, health data anonymization, health data security in the cloud, and secure health-related private data release. Some changes have been made to existing courses in the HIS graduate program. In Security, Privacy and Legal Issues in Health Systems (HRS 2421), we have added 2 guided discussion sessions, 2 student presentations, 2 scholarly papers, and 1 hands-on course project. In Telemedicine, Tele-rehabilitation, and e-Health (HRS 2432), security and privacy issues are described and discussed when each telemedicine platform is introduced in the class. Guest lecturers are invited to explain the details of certain systems, such as the security and privacy of patient records in web portals. In Topics in Health Care (HRS 2902), lectures regarding information security and privacy issues in health systems have been added. In Electronic Health Records (HRS 2490), a faculty member from INS delivers 2 lectures on the security and privacy of EHR records. Finally, 1 discussion session and 1 term paper on personal genomic information security have been added to Data Analytics and Its Applications in Genomics (HRS 2425).Six new educational lab modules have been introduced into various classes throughout the new track. These lab modules include lifecycle management in cloud and health social networks, security policy and auditing issues in the health care environment, authentication and identity management, access control for EHR systems, secure mobile apps and social networks in health care, and HIPAA compliance management. All these labs are closely related to pressing security and privacy issues in the domain of health care such as the cloud, social media, mobile app, identity management, access control, and HIPAA compliance. Instructors from the INS and HIM departments met and discussed the content of these lab modules. Each instructor took the lead of 1 lab module according to his/her expertise. For instance, Valerie Watzlaf in the HIM department guided students to investigate the HIPAA compliance of existing telemedicine systems; LZ led students to evaluate the security of a new EHR system created for the FOCUS Pittsburgh Free Health Clinic (FPFHC) and BP trained students to investigate the security of mobile apps.For students in HI-MI-NI-HIM programs, EHR is one system they should be familiar with. Lab exercises were created for them to get familiar with multiple EHR systems. In the Electronic Health Records (HRS 2490) class, the Virtual Lab system developed by the American Health Information Management Association was used to teach students how to use EHR systems such as the one made by Cerner to manage and protect patient data. We also introduce the OpenEMR (open-emr.org) to students, which is freely available to everyone. Students can make changes on the OpenEMR system to see the differences in the output, which is quite beneficial for them to identify the impact of different authentication methods.Four new seminars have been created. These new seminars are typically related to specific research projects led by faculty members in the HIM and INS departments, with topics in high assurance electronic health  and health IT infrastructure, security and privacy in the cloud and health social networks, secure health care cyber-physical systems, and advanced topics in secure health care information systems. In these seminars, both instructors and students read the current literature and gave presentations that are followed by extensive discussion in the class.Small-scale research projects are created by faculty members and provided to students. Some examples include the security features of a new health IT system created for a free clinic, the security of published mobile health apps, and projects in topics such as access control, social network, and cloud security.LZ has been working closely with FPFHC to create a health IT system for the clinic. Everything is created from scratch, which provides abundant security and privacy research opportunities for students. Students involved in this project can test different security measures and privacy policies and manipulate fake user accounts and medical records to determine the security of the implemented system. They have the opportunity to go through the whole life cycle of secure system development and testing.JJ did extensive research in security and privacy such as role-based access control (RBAC), temporal access control, geo-social-RBAC, anonymization, identity threats, and security and privacy issues in social network systems and the cloud computing environment -22. In tBP has led the development of multiple innovative mHealth systems and telemedicine platforms, including the iMHere system for mHealth and VISYTER (Versatile and Integrated System for Telerehabilitation) for telemedicine ,24. In tWe always encourage students to seek internship experiences in different health care organizations. For instance, many graduate students have the opportunity to work with organizations such as the University of Pittsburgh Medical Center (UPMC) hospitals and Veterans Affairs Pittsburgh Health System as interns. Currently, the HIM department at Pitt has more than 80 active industry partners including multiple UPMC hospitals and various nonprofit health organizations. Students in this new track are specifically encouraged to have security- and privacy-related internship experience with these industry partners.Since the course materials have just recently been implemented, we can offer only a preliminary evaluation report. Pitt’s Collaborative for Evaluation and Assessment Capacity worked closely with the project team to perform the evaluation, which included collecting data according to the project objectives in each course/activity as well as evaluating the impact of project activities on learning outcomes. All new items in the track will be evaluated through observation, pre/post comparisons, surveys, and/or feedback from students and faculty.In general, evaluation activities involve the following:Collecting information regarding student satisfaction and perception toward the new course materials, training approach, and other activities through surveysMeasuring student learning results through performance in courses, projects, or internships and feedback from course instructors or internship supervisorsIdentifying any evidence that students are applying acquired skills in subsequent courses using behavior change checklistsDocumenting any evidence that students are using new knowledge and skills beyond coursework by conducting postgradation/employment surveysIn Fall 2015, 2 courses, Topics in Health Care (HRS 2902) and Telemedicine, Tele-rehabilitation, and e-Health (HRS 2432), were enhanced with security and privacy content. Two brief and informal questionnaires designed by the course instructors were distributed to students in the class at the end of the semester. The questionnaires were aimed at obtaining a general measure of students’ opinions on the new security and privacy contents and pedagogy. In HRS 2902, 3 brief questions were asked, and 4 students responded see . In the During Spring 2016, a Web-based survey was implemented in all security- and privacy-enhanced courses in the new track. This survey asks questions regarding students’ opinions on security and privacy in health systems before and after taking one security- and privacy-enhanced course. By December 2017, 65 students had participated in the survey, and 55 of them provided their answers beyond the basic demographic information. The results reported below are based on the analysis of these 55 students’ answers. Each of these 55 students had taken at least one of the security- and privacy-enhanced courses, such as HRS 2421, HRS 2432, HRS 2902, or HRS 2425. Among these student, 56% (31/55) of students were from the HIS master’s program, 16% (9/55) were from the Health Care Supervision and Management master’s program (HSM), 4% (2/55) students were in the Rehabilitation Science PhD program, and 22% (12/55) were from other master’s programs such as Prosthetics and Orthotics , Rehabilitation Science and Technology , and Nutrition and Dietetics . Details about these graduate programs can be found at www.shrs.pitt.edu/programs. Please note that students in programs other than the HIS master’s program are not required to take security- and privacy-related courses and their future work typically does not require them to have security and privacy knowledge either.Before performing the analysis on the collected data, we noticed that the answers from 3 students were not consistent. Since this Web-based survey was only conducted at the end of the course, instead of before and after the course, some students were confused by the change of terms in the questions for indicating time. Terms used in the questions or statements included now versus then, before versus after, nothing versus thinking back, and after versus prior to. They put some answers to precourse into the box for postcourse and the other way around in questions. For instance, in the now/then questions, these 3 students indicated that they knew significantly more about information security now (after they took the course) and they wanted to take more security courses in the future. One of them actually had already taken more than 1 security- and privacy-related courses in the new track. However, their answers to the before/after questions showed the opposite (did not learn much from the course and did not want to take more security- and privacy-related courses). In this case, we corrected the position of these 3 students’ answers to make them internally consistent, assuming their first answer to this type of question is correct.P<.05 in the Shapiro-Wilk test on each item). Therefore, the answers before and after taking the course are compared with a nonparametric Wilcoxon signed-rank test on related samples. The results are summarized in For the first 2 questions (Q1 and Q2) in the survey, we simply reported the percentage of options chosen by these 55 students since they were basic fact checking after they took the course(s). The mean and standard deviation (SD) were calculated for survey items with 5 options (either from 1=not very much to 5=very much or from 1=strongly disagree to 5=strongly agree). The distribution of the answers from these 55 students were checked and they were not normally distributed ?Students responded with ratings of 6, 7, 8, and 9. This indicates that these students had different levels of concern in security and privacy issues in the health systems before attending the security and privacy lectures.Did the security and privacy lectures provide you with ideas and examples for security and privacy assurance in health care?All 4 students answered yes.Do you plan to take further courses or have the desire to learn more on security and privacy in the future?All 4 students answered yes. Some even indicated the specific topics they would like to learn more about such as access control, authentication, and encryption.What is your perspective on privacy and security in telehealth before taking this course?Seven students (54%) believed security and privacy were important, one student (8%) had concerns, and 5 students (39%) did not see privacy and security as a serious issue.What is your view of privacy and security in telehealth after taking this course?Twelve students (92%) expressed that security and privacy are very important. One student (8%) did not believe security and privacy to be significant issues.Please describe how beneficial the following approaches are in increasing your knowledge of privacy and security in telehealth:Security and privacy issues are mentioned throughout the course and connected to specific projects in telehealth.Twelve students (92%) believed that this approach was beneficial; one student did not answer.Security and privacy issues are presented as a specific topic/module by guest lecturers.Twelve students (92%) believed that this approach was very helpful since these guest lectures provided real world cases demonstrated how security and privacy concepts were applied in current systems. One student (8%) believed this approach was fair.Security and privacy issues are considered as a part of the final project.Twelve students (92%) believed that this approach was beneficial. One student (8%) believed that this approach was not beneficial.Would you be interested in taking a more advanced course in privacy and security? Ten students (77%) answered yes, 2 students (15%) answered no, and one student (8%) was unsure.Q1. I am considering/would consider entering the health privacy and security track within my degree program. Fifteen students (27%) chose yes, and 17 students (31%) chose no. Three student (6%) answered that they were already enrolled, and 19 students (35%) answered maybe.Q2. Did you take any other courses this academic year that included security and privacy modules? Twenty-two (40%) students answered yes, and 33 students (60%) answered no. The courses these students took were HRS 2425, HRS 2432, HRS 2903, and HRS 2421.P<.001), suggesting that students know significantly more about security and privacy after taking one or more security-enhanced courses in this new track. Their opinion of security-enhanced courses also shifted in a positive direction after they took those courses, and all changes were statistically significant according to the related-samples Wilcoxon signed-rank test. In other words, after they took the courses, the students had a statistically significant stronger agreement with the 6 statements (S1 through S6), which indicated that this education program is effective in terms of improving students’ knowledge in security, desire to learn more in this field, and interest in working in this area.The answers to the question (Q3) before and after taking the course are statistically different (P=.01) and S3—Improving knowledge of security and privacy is needed to ensure cybersecurity in today’s health fields (P<.001), which was consistent with their behavior in that they took multiple security-enhanced courses in the track.An independent-samples Kruskal-Wallis test was performed to determine the opinion difference between students who had taken multiple security-enhanced courses versus one such course after they took the course. The result indicated that students who had taken multiple security-enhanced courses expressed significantly higher agreement on 2 statements: S1—Security and privacy content is interesting , and S6 . More specifically, students from the HIS program expressed significantly stronger agreement on S1 than students from HSM, PO, RST, and ND both before (P=.008) and after (P=.04) they took the security-enhanced courses; students from HIS also indicated significantly stronger agreement on S6 than students from HSM, PO, RST, and ND programs after they took the courses (P=.03). In other words, students in the HIS program considered security-related topics interesting before and after the courses and they had significantly stronger desire to take more courses with security and privacy content.A one-way analysis of variance (ANOVA) was performed to determine the opinion difference among students who were in different programs: HIS , HSM (n=9), and others . The ANOVA result indicated that students from different academic programs had statistically significant difference in their answers to 2 statements: S1  was created to provide further details about this security and privacy track to people who are interested in creating a similar track in their programs. The website also provides information about teaching health science to information science graduate students.In close collaboration with the INS security and privacy faculty, we have created a new security and privacy track in the HIS graduate program at Pitt. Enhanced courses, course modules, labs, seminars, and research projects are currently offered to graduate students in this program. Evaluation results were generated from surveys completed by 72 students, and they can be used to guide the further implementation of this new track. We believe this program will generate health informatics professionals with stronger security and privacy skills who will be ready to contribute to the protection of critical health data.


Extensive documentation exists on a range of negative sexual and reproductive health outcomes and rights violations occurring during humanitarian emergencies. We explore two central questions: Do existing policies, services, and research adequately address the SRH rights, priorities and HIV risks of adolescent girls and young women in emergency settings? What are the missed opportunities for holistically addressing the vulnerabilities experienced by those living with HIV during rapid onset disasters and long term, protracted emergencies? Authors review considerations informing real-time decision making, and highlight missed opportunities to apply a gendered lens in the delivery of AGYW-centered SRHR/HIV services.A scoping review identified studies on HIV intervention and outcomes in emergency settings, published in the peer-reviewed literature (2002–2017). This exercise was complemented with a desk review of normative guidance, frameworks, and implementation guidelines on HIV and SRH in emergency responses, and by consultations with subject matter experts.The existing frameworks and guidance pay scant attention to the sexual reproductive health and rights of young women living with HIV (WLHIV), focusing mainly on prevention of mother to child transmission (PMTCT), antiretroviral therapy (ART), HIV testing services, and linkage to treatment services. Applying a gendered sexual and reproductive health lens to the response offers opportunities to identify critical implementation questions, and highlight promising practices, to better tailor current services for AGYW.A plurality of competing needs crowds out dedicated time and space to effectively integrate HIV and sexual and reproductive health interventions in emergency settings. Political will is required to advance multi-sectoral cooperation, through joint planning, rights-informed learning and integrative responses, and to promote creative solutions for ART continuation, drug supply and HIV testing, treatment and care. Recent advancements in policy and practice would suggest that a more AGYW-centered response is feasible.The online version of this article (10.1186/s12978-019-0710-0) contains supplementary material, which is available to authorized users. Humanitarian emergencies have been an episodic disruptor of human immunodeficiency virus (HIV) service delivery, complicating the ability to track patients on antiretroviral treatment (ART), maintain and access care records, rupturing services and supply chains, and even displacing care providers, all of which tend to occur in health systems that may already have known deficits . FurtherAs explicated in the literature, in a variety of emergency contexts, women and girls are subjected to gross human rights violations stemming from ingrained gender inequality, including reduced access to HIV prevention and reproductive health services, forced occupational exposure, rape as a weapon of war, trafficking, coerced, transactional, and/or survival sex to support self and dependents or family , 3–6.As the frequency and duration of humanitarian emergencies increases, the consequences for women and girls are dire. According to the World Health Organization (WHO), more than half of maternal deaths occur in fragile and humanitarian settings . By UNAIRecognizing the unique pathways through which humanitarian disasters complicate the global response, a Declaration of Commitment on HIV/AIDS in June 2011 was passed at the United Nations General Assembly Special Session (UNGASS) on HIV/AIDS, stating that, “populations destabilized by armed conflict ... including refugees, internally displaced persons and in particular, women and children, are at increased risk of exposure to HIV infection” [A cursory review of existing manuscripts, frameworks, and guidelines substantiates that adolescent girls and young women (AGYW) with HIV are among the most vulnerable in emergency contexts. Yet, there is little guidance that exists, articulating an integrated and developmentally-sensitive approach to HIV care and treatment, and sexual and reproductive health (SRH). While stakeholders may be able to utilize globally recognized sources such as the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR), the Inter-agency Standing Committee (IASC) Task Force for HIV/AIDS, the SPHERE Network and Joint United Nations Programme on HIV/AIDS (UNAIDS) guidance for service delivery, modifying these for local environments affected by emergencies is largely uncharted territory in countries explored in this review. Even the most robust models of prevention, care and treatment of HIV interventions require simplification and adaptation in a state of crisis or emergency, and revisions or special supplements for countries during complex emergencies, remain as gaps.The objective of this paper is to examine existing policies and implementation approaches identified through a scoping review in relation to the provision of HIV and Reproductive Health services for AGYW, and to surface recommendations that could transform the current programmatic paradigm. This review also highlights expert suggestions that stakeholders can draw from, to enhance responsiveness to the needs and vulnerabilities in serving this group.Between June 2017 and December 2017, we searched PubMed, Embase, the Cumulative Index of Nursing and Allied Health Literature (CINAHL), and Google Scholar for studies, evaluating whether current emergency response standards and practice adequately respond to the unique risks, vulnerabilities, and developmental needs of adolescent girls and young women (10–24) living with HIV. Key search terms included: HIV and adolescents and humanitarian assistance; Humanitarian medicine; (pediatric HIV) AND (conflict OR humanitarian OR crisis OR emergency); child or youth and HIV and (crisis or conflict); ((adolescent) AND HIV) AND (emergency OR conflict OR crisis OR humanitarian); ((((HIV) AND conflict) OR disaster) OR crisis) OR humanitarian); ((HIV care) AND pregnant) AND (humanitarian OR crisis OR emergency OR conflict); ((HIV care) AND pregnant) AND (humanitarian OR crisis OR emergency OR conflict); famine and HIV.We assembled a database to document potentially relevant studies. To identify other studies that we might have missed, we reviewed reference lists of articles selected in our primary search.We included randomized controlled trials (RCTs), cross-sectional, observational cohort, retrospective cohort, pre-post- and qualitative studies. Qualitative studies were included if they were based on primary data collection. Systematic reviews and retrospective studies were screened if they included information on the intersection of SRH across the clinical cascade for AGYW. We also conducted a secondary review of national policies, global frameworks, and international guidelines from countries with a high burden of HIV that experienced significant emergencies in the study period, to augment the prioritization process.The following inclusion criteria was used to select studies: primary or secondary data on HIV prevention/sexual health, clinical or psychosocial outcomes; reported on a clinical, policy, legal, or programmatic intervention; reported on population outcomes within the context of emergency programming ; or clearly included adolescent girls, young women, or pregnant women aged 10–24 as a study population.Abstracts were reviewed by two independent abstractors, who included articles meeting the inclusion criteria stated above. Independent review of the primary study selection was completed by at least one other reviewer. Discrepancies were resolved by consensus. An independent manual search, primarily but not exclusively from manuscript references, identified additional reports for inclusion. Potentially duplicative studies were flagged for review and resolution by group consensus. Full text review by the entire study team and group consensus was required for inclusion of reports on which there was uncertainty.Data abstraction was conducted by five independent researchers summarizing information about the population, intervention, comparator, outcome, and context/setting into standardized tables. Independent review of the data abstraction was completed by at least one additional researcher.We examined whether current emergency response standards and practice adequately respond to the unique risks, vulnerabilities, and developmental needs of adolescent girls and young women (10–24) living with HIV.What are the priority changes deemed most critical for ensuring continuity of HIV treatment and care in emergency settings?What are key barriers to the provision of SRH services for AGYW?What key priorities and opportunities exist to reinforce SRH for HIV positive AGYW and those most at risk?What are some promising or effective approaches, interventions or service delivery models for integrating SRH into HIV programming in a humanitarian settings?What stakeholders, specifically regional and/or international bodies, are best positioned to help advance the HIV-SRH integration agenda to better serve AGYW in conflict-affected areas?We conducted consultations with field-based experts, eliciting expert opinion on program implementation and stakeholder coordination experiences with AGYW programming, HIV and SRH in emergencies, from current or prior work in Democratic Republic of Congo, South Sudan, Côte d’Ivoire, Nigeria, and/or across West and Central Africa. The consultations provided additional perspective, given the paucity of peer reviewed literature on this subject matter, and highlighted areas for further dialogue and inquiry, and areas for future investigation. We aimed to learn the following from these consultations:The search yielded 1250 articles, of which 26 articles met the inclusion criteria for this review. Table There was a paucity of evidence on the intersection of sexual and reproductive health and HIV services for AGYW in emergency contexts. No article assessed specific interventions - instead we saw a combination of review articles, case studies and commentary pieces.Given the heightened risk of sexual violence, sexually transmitted infections (STI), termination of pregnancy and early loss, premature delivery, stillbirths, delivery-related complications, and neonatal and maternal mortality, there is a missed opportunity for cross-examination of these issues in emergency settings beset by high HIV prevalence or low coverage with HIV and/or SRHR interventions.The content of key global frameworks, normative guidelines and global standards for emergency- and/or disaster-related action, response and recovery, was reviewed for clarity on existing guidance on programmatic decision making in emergency/post-emergency and resource constrained environments. Table We identified 20 global frameworks that address emergency response and recovery. These frameworks generally focused on planning, activation, coordination, monitoring, governance and information sharing, with attention paid to the need to enhance programming directed at the nexus between the humanitarian and development sectors. Considerations on programming responses to hunger, poverty, education, water, shelter, and ecosystem management were consistently addressed. Authors ascertained that the normative guidance is generally weak on sexual and reproductive health, HIV and the specific developmental needs of adolescent girls and young women. Among the frameworks listed, none mentioned HIV explicitly or gave specific recommendations, although a few (five of the 20 identified) did mention health, healthcare, or the health system peripherally.We reviewed established normative sources around which public health emergency response practitioners organize their health and HIV/AIDS efforts. These include: the Inter-agency Standing Committee Guidelines for HIV AIDS Interventions in Emergency Settings ; the SphThe Minimum Initial Service Package for Reproductive Health (MISP) is a compilation of life saving measures, designed to prevent and manage the consequences of sexual violence; prevent excess maternal and newborn morbidity and mortality; reduce HIV transmission; and plan for comprehensive RH services beginning in the early days and weeks of an emergency . As partVigilant attention to prevention needs in the context of emergency settings could provide the additional benefit of detecting of acute HIV infection, a need which is all the more critical for AGYW in the reproductive age group. Existing frameworks identify (sometimes indirectly) the specialized need for the availability of post-exposure prophylaxis (PEP), and more recently, for pre-exposure prophylaxis (PrEP). The WHO’s “Clinical Management of Rape (CMR) Survivors: Developing Protocols for use with refugees and internally displaced persons - Revised Edition” provides specific protocols and guidance on the use of PEP, as well as treatment of sexually transmitted diseases, without specifically mentioning methods to reach AGYW. CMR is an essential component of MISP and should be included as part of integrated Health and GBV programming. The guidance stipulates conditions under which health providers should assess high HIV risk, based on general HIV prevalence and known or unknown perpetrator risk . This gun = 671) reached the clinic in the critical 72 h window. Primary reasons for the delay in seeking services were fear, shame, and lack of knowledge on the available treatments/services. Critically, follow up for prevention services , however, was low [A 2014 study  on patterns of sexual violence, survivor characteristics, and components of the Médecins Sans Frontières (MSF) response across two provinces  in the Democratic Republic of Congo found that only 46% of survivors , medical care , prophylaxis for STIs , HIV PEP , vaccination for hepatitis B and tetanus, and wound care if indicated), psychological counselling, preparation of a medico-legal certificate, medico-legal support if requested, and safe shelter and external referral for social assistance for specific cases... .The Interagency Task Team HIV in Humanitarian Emergencies  has recoThe IASC Task Team on Accountability to Affected Populations (AAP) and Protection from Sexual Exploitation and Abuse (PSEA) was established in 2012 in order to foster a culture of accountability and protection from sexual exploitation and abuse at all levels of the humanitarian system . It encoWhile HIV is often viewed as a lesser priority in emergency contexts - particularly due to other competing demands, the weakened health infrastructure and low availability of medical professionals - skilled cadres who focus on HIV treatment and care needs of PLHIV, can increase clinical capacity and help alleviate workforce constraints. Supplementing the health cluster and disaster response teams with HIV specialists can be beneficial beyond the scope of HIV and AGYW services. A 2002 study by O’Brien et al. in the Democratic Republic of Congo found that “doctors caring for HIV patients also worked in the adult medical, paediatric, emergency and TB wards, and counselors undertook general psychosocial counselling for HIV negative people (e.g. post-traumatic counselling) as well as HIV related counselling and education activities .” AdditiAs HIV services are built out for AGYW and particularly survivors of sexual violence in emergency contexts, follow-up must be stressed as a vital aspect of programming. This support can also take the form of community-led outreach. In an example from South Sudan, a female-centered WASH activity  increased their vulnerability, when sexual harassment and assaults were common and grossly concealed at target sites. After women and girls self-reported sexual assault during trips to the latrines and water collection points in the evenings, they organized themselves for group water collection and recurring meetings, forming a support system for those victimized and others. This local forum enabled the implementing partners to offer medical, psychosocial and case management services . Most imThe imperative to reach AGYW must be rooted in rapid assessment of specific needs, meaningful engagement of those living with HIV and affected post-conflict, and where appropriate integrated services. Identification and segmentation of a subpopulation of young women in each West and Central African country looks different and is critical to determine, develop and deliver the right (and most) impactful interventions. For example, although country dependent, understanding the profiles of AGYW and young mothers is a critical step before reaching consensus about the most essential interventions. Varying contexts will call for tailoring of HIV and SRH service delivery strategies to adolescents within the general population, those living with HIV, first time mothers, AGYW engaged in sex work, and other competing priorities prone to require support.As stressed in the MISP and IASC frameworks, coordination and continuous communication among partners working in HIV and SRH are both paramount to support host country efforts. Host governments, US Government/PEPFAR, the Global Fund to Fight AIDS, Tuberculosis, and Malaria field teams, UNAIDS coordinator, a member of the humanitarian country team, the Health Cluster, World Food Program, and lastly a host of donor-funded implementers and humanitarian actors, need to exchange information. Having one or multiple agencies serve in a convenor role may help facilitate timely and accurate reporting of current and shifts in activities. This enables all to have a picture of geographic, intervention and resource areas. In addition to these stakeholder meetings, feedback from one regional West and Central Africa health office Director, also underscored the need to adapt technical assistance, monitoring and supervisory approaches and simplify these based on what is the most feasible in one country situation.The authors mapped a number of issues below based on their predominance across study content. For the subject matter mentioned as requiring special attention, only four (4) articles covered programmatic considerations in relation to AGYW, while promising and evidence-informed interventions were largely lacking for targeting this group. The majority of studies, focusing on HIV service provision, address approaches to reach the general population and called for alternative programmatic solutions when these are disrupted. Therefore, a key shortcoming of the studies is the number of unanswered questions -- what is being done to reach young girls and what can be learned about how AGYW living with HIV overcome service delivery barriers; and for those that ably seek, receive and remain linked to treatment, care and SRH services in countries plagued by insecurity, what factors are at play?Interventions tailored for AGYW with known HIV status and those at high risk should take into account survivors of rape, sexual violence, exploited young girls and women engaged in sex work and transactional sex. Specifically, increased research and documentation is needed on how to reach young adolescents through facility- or community based care, through their social and sexual networks, and through task-shifting support. The importance of integrating SRH and HIV services in West and Central Africa has been highlighted in high level forums such as the 2018 international AIDS conference alongside the threats to AGYW health and approaches to advance the HIV prevention and child protection agenda. While the number of Calls to Action  for addrGiven the paucity of peer-reviewed literature on this subject matter, we aimed to ground our scoping review with the perspectives of practitioners who have substantial experience coordinating HIV and SRH services in emergency settings. In February of 2017, we held individual phone interviews with seven experts and one in-person meeting with key global health institutions, including: UNAIDS, UNICEF, USAID West and Central Africa. We aimed to learn: key priorities to reinforce SRH messages and services within HIV programs for AGYW and core recommendations for carrying these out, based on their collective implementation experience.All respondents ranked obstetric and antenatal care for pregnant women living with HIV; antiretroviral drugs and other HIV commodities security and GBV prevention and services for rape services, as critical areas of focus. Supporting AGYW through household and community mobilization to address their heightened risk for of HIV from rape and sexual exploitation was re-emphasized repeatedly as was the partner coordination and host government leadership intangibles.Five common themes for prioritization within emergency settings and programs tailored to young AGYW and those of reproductive age, were identified by experts:• Women’s and Girls’ Protection and Violence Response, including questions around effective responses and realities of some operational constraints/limitations of targeting adolescent girls and other survivors of rape, sexual and intimate partner violence • Pregnancy and PMTCT, with a focus on the increased vulnerability of adolescents, and approaches for ensuring service providers can cater to needs of mother and child with known and unknown HIV status• Poor access to the health system, highlighting the need for more research on access to contraceptives, ART drugs and viral load monitoring through service delivery platforms in an emergency setting while addressing compounded stigma, discrimination and varying knowledge, attitudes and practices of AGYW• Mental health and psychosocial support, particularly a need for more evidence on the most feasible, cost effective and useful individual as compared to peer-group based interventions.• Voice, accountability, and empowerment, with a concern for new modalities to amplify and leverage these attributes so they can translate into gains across community mobilization, quality of care, and agency of AGYW while mobile, displaced and/or resettled.The content of our consultations provided practical insights on ways to align with the key tenets outlined in the 2015 Interagency Task Team on HIV in Humanitarian Emergencies guidance . Their r• Identify appropriate platforms  for AGYW to understand the range of  services and help facilitate destigmatized care and treatment support. For AGYW affected by violence, improve integration of GBV responses with Health programming• Prioritize ART and life saving medicines for those living with HIV and pregnant to prevent mother to child transmission and strengthening cross border programming and mobile service outlets that aim to reach AGYW• Strengthen the emphasis on PMTCT for pregnant women within the MISP, particularly access to modern contraceptive options for women living with HIV, which continues to be a key underemphasized element of effective PMTCT programming. HIV development actors should ensure continued access to PMTCT services by rapidly reprogramming their activities during emergencies, while ensuring that critical elements of the MISP are being provided for women in need of RH services;• Share culturally-sensitive, age- and language- appropriate information with girls and their caregivers, including ways to prevent, treat and manage HIV and STIs, space pregnancies, address menstrual hygiene management (MHM), negotiate safer sex, and on how to access services, part of holistic programming• Better understand and respond to the varied nuances of programming for hidden AGYW populations, including female combatants, sex workers, girls engaged in transactional sex, girls in forced and/or early marriages, women with substance use dependencies, transgender women, and other special sub groups, rather than assuming homogeneity across females seeking or receiving HIV services• Support mental health services as part of outreach and in clinic settings, including creative health workforce solutions that address mental health needs. Equip them, and other providers (plus lay workers) through training and task shifting strategies, thus expanding the pool of human resources for health in facilities and communities• Ensure humanitarian actors, HIV and other health implementing partners remain in consistent communication and when needed engage in joint planning through the Health Cluster and other platforms• Explore novel data solutions and architecture at all levels, decentralized to national, to improve tracking across settings and safeguard patient safety, including mobile data, biometrics, and/or cloud-based health information systems• Update global guidelines and policies to reflect strategies and implement country-specific operational plans for integrated HIV and SRH services in the humanitarian emergency setting• Maintain flexibility with funding sources and openness to redirection, reallocation and resources and where possible integrating SRH and HIV in other routine programs deemed as first tier priority in a given country Opportunities abound to advance a prioritization agenda for AGYW-centered care at policy, program and strategic information levels to improve quality and scope of services, especially in emergency settings. The authors assert that applying a SRH lens in even the most challenging operating environments, is as essential as ensuring a well-coordinated, locally led multi-sectoral response, if this special population is not to be left behind. Clearly defining in practical terms approaches that prioritize identifying (then linking) adolescent girls and young mothers living with HIV and at most risk to services, remains a critical step. Integrating humanitarian partner activities with the HIV response, may offer the best platform for reaching AGYW in countries affected, if client-centered. In order to go beyond topical gaps, identified from the scoping review, country specific plans, investments and research cannot be confined to a reliance on Calls to Action and recent guidelines alone. Learnings from what is working in SRH services in complex emergency settings in Africa, must be captured by implementers and nuanced at meeting the needs of AGYW of different ages. Rigorous documentation of effective practice requires more attention, particularly in rapid/sudden onset emergencies. Stakeholders must maintain a heightened awareness of sociological context of a particular emergency setting while adapting interventions for targeting AGYW to access services.A French translation of this article has been included as [see Additional file A Portuguese translation of the abstract has been included as [see Additional file Additional file 1:Country Snapshots of HIV Service Gaps and Opportunities in Emergency Setting. (PDF 58 kb)Additional file 2:Translation of this article into French. (PDF 312 kb)Additional file 3:Translation of the abstract of this article into Portuguese. (PDF 97 kb)


The release of the Healthy Brain Initiative Road Map for Indian Country inspired the International Association for Indigenous Aging (IA2), Association of State and Territorial Health Officials (ASTHO), and the Centers for Disease Control and Prevention (CDC) to develop health communication materials to promote heart health and brain health among states with American Indian and Alaska Native (AI/AN) communities. IA2 engaged public health, tribal health, and brain health experts to inform the key messages and intended audiences. The final package includes two posters, one flyer, one provider guide, four radio public service announcements, and two short videos. Tribal health officials and state health are encouraged to distribute the resources through senior centers and inter-tribal organizations, healthcare facilities, administrative offices, tribal newspapers/radio stations, and as mailers to tribal members. The session will focus on how the resources raise awareness of and promote action on heart and brain health among AI/AN communities.