Liver cancer is a highly fatal condition disproportionately impacting American Indian populations. A thorough understanding of the existing literature is needed to inform region-specific liver cancer prevention efforts for American Indian people. This integrative review explores extant literature relevant to liver cancer in American Indian populations in Arizona and identifies factors of structural inequality affecting these groups. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines informed the methodology, and a literature search was conducted in PubMed, EMBASE, CINAHL, and PsycInfo for articles including Arizona American Indian adults and liver disease outcomes. Seven articles met the inclusion criteria in the final review. Five of the studies used an observational study design with secondary analysis. One article used a quasiexperimental approach, and another employed a community-engagement method resulting in policy change. The results revealed a lack of empirical evidence on liver cancer prevention, treatment, and health interventions for American Indian populations in Arizona. Research is needed to evaluate the high rates of liver disease and cancer to inform culturally relevant interventions for liver cancer prevention. Community-engaged research that addresses structural inequality is a promising approach to improve inequities in liver cancer for American Indian people. Hepatocellular carcinoma (HCC) and intrahepatic bile duct cancer (cholangiocarcinoma), hereafter referred to as liver cancer, are highly lethal conditions with rapidly increasing mortality rates across the globe ,2. ThereFurther complicating matters, nationally aggregated data do not adequately portray the pertinent variation in significance between American Indian groups and the geographic differences in disparities, liver cancer incidence rates, and changes over time . There aThis article will focus on Arizona-based American Indian populations to inform the larger scientific community by conducting a culturally tailored review. This targeted review may provide practices that could be adapted for other high-risk indigenous populations around the world. The objective of this article is to summarize extant literature relevant to liver disease, liver cancer, and American Indian populations in the Southwest region of the United States (US). Gaps in knowledge in liver cancer prevention will be identified, along with thorough discussion of structural inequities disproportionately affecting liver cancer for American Indian people.Globally, liver cancer is the sixth most diagnosed type of cancer and the fourth leading cause of cancer-related mortality . In 2018Although advances in liver cancer research have informed cancer prevention efforts and the incidence of liver cancer in the general US population is starting to level off, this promising trend is not reflected in American Indian populations . ChronicThe objective of this integrative literature review is to address the current gap in knowledge on the specific components and outcomes of studies on liver disease and/or liver cancer prevention for American Indian communities in Arizona. The aim of this review is to identify current best evidence and specifically answer the following questions: (a) What are the incidence and prevalence of liver disease and/or liver cancer for American Indian populations in Arizona?; and (b) What treatment and prevention strategies have been implemented to address liver disease and/or liver cancer for American Indian adults in Arizona ?The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines informed the review process. A literature search was conducted across four major academic databases, PubMed, EMBASE, Cumulative Index to Nursing and Allied Health Literature (CINAHL), and PsycInfo. Due to the research questions, there were no limitations on publication dates to endorse evaluation of extant literature. The search strategies in PubMed and CINAHL used the National Library of Medicine Medical subject headings (MeSH). The development of key terms and search strategies were done in collaboration with a librarian from the University of Arizona Health Sciences Library. All suggested variants of MeSH terms were included in database searches. A combination of the following key terms with Boolean phrases “AND”, “OR” were utilized in the search strategy: “Liver disease”, “Liver cancer”, “Liver neoplasms”, “Hepatocellular carcinoma”, “Nonalcoholic fatty liver disease”, “Liver dysfunction”, “American Indian”, “Native American”, “Indigenous persons”, “American Natives”. Detailed key terms for each database are provided in It is important to note that while the term American Indian was used for this manuscript due to its widespread use in the research literature, we recognize that there are more inclusive terms that can be used to describe our focused population. As mentioned, we included other terms in our searches such as Native American, Indigenous persons/people, and American Natives.Article selection was performed by recording the numerical results obtained from each individual search, including individual keywords, and combined controlled vocabulary for each database in an Excel spreadsheet. This information was then organized in a table. Inclusion criteria included full-text and English language articles from peer-reviewed journals. Additional criteria for article selection included studies focused on Arizona American Indian populations, ages 18 years and older, and liver disease categories  as primary or secondary outcomes. Studies that focused on children and/or adolescents, studies that included participants that did not identify American Indian participants, and studies that did not have liver disease as a major outcome were excluded.Search result files from each database were imported by K.B. into the Rayyan Systems Inc. platform, a collaboration and research tool to collect and organize search results, detect duplicates, and remove unrelated articles in a systematic matter. After removing duplicates in Rayyan, coauthor E.A.V. uploaded the remaining results into EndNote, a citation manager software, to detect any additional duplicates. After additional duplicates were removed in EndNote, the reference list was then uploaded back onto Rayyan where coauthors E.A.V. and K.B. independently screened the articles generated from the literature based on inclusion/exclusion criteria. To further categorize liver disease outcomes, the investigative team utilized a labeling system during the screening process which included the categories of: Hepatitis, HCC, NAFLD, Cirrhosis, and Alcohol-related Liver Disease (ALD). The team also utilized labels to categorize different geographic regions of the studies to identify the focus population, including North American Indigenous , US American Indian, Southwest US American Indian, and Arizona American Indian. n = 87), North American Indigenous  (n = 76), US American Indian (n = 36), HCC (n = 28), Southwest US American Indian (n = 11), Arizona American Indian (n = 11), NAFLD (n = 9), Cirrhosis (n = 9), and ALD (n = 3). It is important to note that many articles had more than one subcategory assigned to them. A total of 1681 articles did not meet the inclusion criteria during the title and abstract review. From the remainder, 10 were included to be part of the full-text screening, but 3 were published abstracts and were, therefore, excluded. A total of 7 articles were selected for inclusion in the integrative review. Analysis was complicated by variation in study design and methodology. The database search yielded 2167 results. Once duplicates were removed, a total of 1691 were screened for inclusion. To provide more context as to the type of results that were obtained from the searches, the following are the results from each of the different subcategories that were utilized when screening articles: Hepatitis  had an observational study design with secondary analyses conducted for epidemiological surveillance measures. Medical records were the primary source of data collection for 71% of the studies. One study used a quasiexperimental, pre–post-test design using biomedical specimens  and radiographic imaging as measures [Most of the included articles  from 1975 to 1988. In 1990, Sievers et al.  presenteA few years later, Lee et al. (1998)  studied It was not until 10 years later when two more articles were able to elaborate on liver conditions among American Indian communities residing in Arizona. Koska et al. (2008)  evaluaten = 1496) had chronic liver disease. Of those, 17.9% were considered in the stage of decompensated cirrhosis and other causes included 6.9% of patients with hepatitis C, 41.5% for alcohol, and 12.8% for NAFLD. Men had a higher prevalence of chronic liver disease, ALD, and chronic hepatitis C; while women had a higher prevalence for NAFLD. Male patients aged 40–49 had the highest prevalence of chronic liver disease, chronic hepatitis C, and alcohol-related chronic liver disease and females aged 50–59 had the highest prevalence for chronic liver disease and NAFLD. It is worth mentioning that cause of chronic liver disease was not determined for 26.1% (n = 391) of patients and many met at least one of the criteria for NAFLD, including 34.8% with diabetes and 59.6% with obesity. Due to this cause, it is likely that prevalence data for NAFLD is significantly underestimated.During the same year, Bialek and colleagues (2008)  cross-seTwo articles were published a few years later emphasizing the epidemiology of hepatitis A and C. The first was in 2012 where Erhart and Ernst  investigAmerican Indian communities experience high rates of liver cancer incidence and mortality. Despite the clear need to develop effective liver cancer prevention strategies, this review has confirmed that a gap remains among American Indian populations and the scientific literature. The gap includes a lack of early screening and interventions addressing the burden of liver disease progressing to liver cancer for tribal communities in Arizona. Most of the included articles focused on outcomes related to alcohol-related cirrhosis, hepatitis, chronic liver disease, and liver mortality as part of surveillance systems. Although there was mention of the need to develop interventions addressing sociocultural factors contributing to disparate findings , there iTo better understand the larger context of liver cancer in American Indian populations, the influence of structural inequity on social determinants of health must be included in the scientific literature. Longstanding racism and discrimination have created structural inequities shaping social determinants of health that heavily influence contemporary lifestyle-related health disparities in liver cancer and result in poorer health outcomes for American Indian people ,39,40,41Further contributing to the burden of liver cancer in American Indian groups is severely underfunded systems that affect access to health services . For exaThe issue of liver cancer for American Indian people may be more complex than what is conveyed in the literature. To precisely assess the state of liver cancer, updated data on the burden of liver disease for American Indian communities in Arizona is needed. For most of the studies in the review, data was greater than 10 years old. Additionally, misclassification of data likely caused underreporting of liver disease and cancer rates . Similar®) is a noninvasive tool to assess liver steatosis and fibrosis that can be performed in the outpatient clinics and communities with immediate results and excellent reproducibility [Importantly, early detection of liver disease remains critical for health promotion and prevention of advanced stages of disease. As such, it is eminent to recognize the need of available and cost-effective treatment and screening alternatives for the prevention of advanced liver disease. Recent evidence suggests the use of nonenhanced magnetic resonance imaging (MRI) as a reliable method for HCC surveillance among high-risk individuals. MRI’s advantages include its advanced performance, short scan times, and the lack of contrast agent-associated risks . This sccibility . In factcibility . This efcibility . SimilarAlthough structural inequality is interconnected with liver cancer health disparities, the importance of the strength and resilience within American Indian communities must be emphasized as a social determinant of health . When reCoalescing objectives and priorities with existing clinical and policy systems is another mechanism to share resources and attain mutual benefit. This has been demonstrated by efforts to reduce rates of liver cancer in the Cherokee Nation Health Services, who implemented an HCV testing policy that interfaced with clinical healthcare providers . ScreeniThough the integrated programs described can improve access to care and liver cancer preventative services, broader intervention and prevention strategies are needed to address disparities in liver cancer incidence and risk factors for American Indian communities in Arizona. A comprehensive approach would address the many factors that contribute to health disparities, including structural inequity. Culturally congruent, community-based interventions are necessary to support healthy behaviors and promote best outcomes. Future research may involve interdisciplinary teams and community partners to explore ways to improve liver cancer prevention strategies that promote health equity in liver cancer for American Indian communities by applying integrated scientific approaches and community-engaged research methods.This review has several potential limitations. Limitations in the articles analyzed included small sample sizes, and lack of grounding in theory that was consistent across the studies reviewed. Generalizability of the findings is limited due to the scope of the review and intention to refine the population of focus. Studies were limited to specific geographic areas, types of data sources, and methods. Most studies relied on secondary analysis of existing data and surveillance. An additional limitation was the outdated sources included in this review. There is a substantial need for updated evidence to truly understand the incidence and prevalence of liver cancer in American Indian communities in Arizona. Finally, an assessment of methodological quality was not incorporated into the review process due to the heterogeneity of included studies.American Indian populations are largely underrepresented in the liver cancer prevention literature, particularly when considering modifiable liver cancer risk factors. To date, there is scant scientific knowledge focused on behavioral, social, and cultural factors to promote engagement more effectively in early screening and detection for liver cancer in this high-risk adult population. Additionally, there is a lack of empirical evidence on both liver cancer prevention and treatment for American Indian communities in Arizona. Our findings suggest there is no prior research ensuring American Indian adults understand what liver cancer is, why they are at risk for developing it, and what they can do to stop the progression of liver disease or reverse their condition. Another challenge not addressed by the literature is the prevalence and effect of NAFLD and other obesity-related liver cancer risk factors, independent of alcohol consumption, for American Indian populations. Lastly, if risk factors are identified, there is no clear evidence how to provide treatment options to participants that may be accessible, particularly for those in rural remote settings, and culturally and clinically relevant. More research is needed to evaluate the high rates of liver disease and cancer to inform culturally relevant interventions for liver cancer prevention and treatment.


Time-restricted eating (TRE), a dietary approach limiting the daily eating window, has attracted increasing attention in media and research. The eating behavior in our modern society is often characterized by prolonged and erratic daily eating patterns, which might be associated with increased risk of obesity, diabetes, and cardiovascular diseases. In contrast, recent evidence suggests that TRE might support weight loss, improve cardiometabolic health, and overall wellbeing, but the data are controversial. The present work reviews how TRE affects glucose and lipid metabolism based on clinical trials published until June 2021. A range of trials demonstrated that TRE intervention lowered fasting and postprandial glucose levels in response to a standard meal or oral glucose tolerance test, as well as mean 24-h glucose and glycemic excursions assessed using continuous glucose monitoring. In addition, fasting insulin decreases and improvement of insulin sensitivity were demonstrated. These changes were often accompanied by the decrease of blood triglyceride and cholesterol levels. However, a number of studies found that TRE had either adverse or no effects on glycemic and lipid traits, which might be explained by the different study designs  and study subject cohorts . To summarize, TRE represents an attractive and easy-to-adapt dietary strategy for the prevention and therapy of glucose and lipid metabolic disturbances. However, carefully controlled future TRE studies are needed to confirm these effects to understand the underlying mechanisms and assess the applicability of personalized interventions. One cycle of this molecular machinery takes approximately 24 h and controls the expression of so-called clock-controlled genes (CCG), which include key metabolic transcription factors and enzymes generating circadian oscillations of metabolic functions , which can adjust (entrain) circadian rhythms in peripheral tissues. In mice fed with high-fat diet (HFD) and in mouse models of obesity, altered rhythms of core clock and a reorganisation of whole circadian transcriptome were observed –29. In hBecause of the tight interaction between the circadian clock and metabolism, timing of eating is an important parameter for modulating body weight and metabolic state. First evidence was obtained in mouse studies showing that animal feeding in the light  phase leads to a desynchronization between peripheral tissues and the central clock and induces weight gain and metabolic disturbances –34.Studies involving humans provide similar results. Shift work or chronic jetlag and, as a result, consuming meals at the “wrong” or unusual time increase the risk of developing type 2 diabetes, cardiovascular diseases, and obesity , 12. Thipm) causes shift in the postprandial period, overlapping with the sleep phase  induces higher blood glucose levels and worsen glycemic control in subjects with an impaired glucose metabolism compared with a reverse pattern of meal composition . In agreTaken together, most published studies suggest that early eating is in alignment with our metabolic clock and therefore might be beneficial for metabolic health.In our modern society, prolonged and erratic daily eating patterns often take place. In American and Indian adults, eating periods of 15 h or longer every day were observed in more than half of the individuals. In addition, more than a third of the daily caloric intake occurred in the evening , 58. Thiad libitum HFD feeding  has attracted increasing attention in public media as a strategy to lose weight and improve overall health. First data on TRE were collected in rodents where such diet is defined as “time-restricted feeding” (TRF). In mice, TRF increases the amplitude of circadian clock rhythms and is protective against HFD-induced obesity, glucose intolerance, leptin resistance, hepatic steatosis, and tissue inflammation compared with  feeding , 61.In humans, the increased research interest to TRE initiated a number of intervention trials evaluating the effects of several TRE regimens with daily eating periods between 4 and 11 h on healthy individuals or participants with metabolic abnormalities  levels decreased significant in five TRE-studies , 78, 87,The present work indicates that the effects of TRE on glycemic control are apparently less variable than effects of TRE on plasma lipid profiles. One possible explanation of this phenomenon might be the known diurnal rhythm of glucose tolerance, which decreases from morning to evening and night, whereas it is established that lipid circadian rhythms show substantial inter-individual variability .Taken together, TRE represents a promising and simple dietary approach for the prevention and therapy of disturbances in glucose and lipid metabolism  in the general population  and medical practice. Published TRE studies included several different subject groups varying from lean and healthy adults –78, 87, vs 9 h vs. 12 h) has to be performed in the future studies upon the careful controlling of caloric intake as discussed below.Further, there is a range of research gaps and open questions in this field of TRE research, which need further investigation. The main question raised is the reason for the inconsistencies in metabolic outcomes between TRE studies. This might be explained by the different study designs  and study subject cohorts  as already mentioned above. The next important limitation is that the wide spectrum of TRE regimens with daily eating periods between 4 and 11 h and food consumption early (eTRF) or late in the day (lTRE) makes the dietary effects scarcely comparable. In particular, optimal duration of the eating window is unknown, suggesting that a direct comparison of varying eating windows  did not change or even worsen blood glucose, beta-cell responsiveness, and lipid levels  and early chronotype (“larks”) are the two extremes which strongly differ in peak times of metabolic function, body temperature, cognitive faculties, and sleeping . Most published trials reported a reduction of energy intake because individuals are often not able to consume all usual food quantity within the limited time window. Nevertheless, four carefully controlled or short-term (4–5 days) TRE trials revealed beneficial effects on the glucose metabolism without caloric restriction or weight loss , 76, 84,via autophagy activation, although relevant publications are sparse. In rodents, intermittent fasting regimen with 24-h fasting periods preserved beta-cell mass in obesity-induced diabetes via the autophagy–lysosome pathway , which leads to the depletion of liver glycogen stores and a metabolic switch from lipid/cholesterol synthesis and fat storage to mobilization of fat through fatty acid oxidation and fatty acid-derived ketones . Further pathway  and a sile blood . Some dale blood , 95. MorRev-Erbs . In partectively . Notablyectively . Howevervia conducting an isocaloric TRE); (2) directly comparing effects of eTRE and lTRE; (3) comparing varying eating window duration; (4) in long-term studies; (5) in a large number of study participants; (6) comparing TRE effects in subjects with different chronotypes; (7) including analyses of physiological and molecular mechanisms underlying the TRE-induced changes. In particular, calling for research that balances feasibility of TRE interventions  with long-term adherence and metabolic benefits could be recommended.Taken together, further human trials are needed to investigate effects of TRE: (1) carefully monitoring macronutrient and calorie intake . Solely, four trials will be directly comparing TRE at different daytimes. Moreover, none of the ongoing trials aims to compare TRE in individuals with different chronotypes, although the subjects’ chronotype will be assessed in several studies. In consequence, even though many TRE trials are ongoing, it remains unclear if these trials will be sufficient to answer all the abovementioned research gaps and formulate dietary recommendations for the general public.TRE represents an attractive and easy-to-adapt dietary strategy for the prevention and therapy of glucose and lipid metabolic disturbances. It might be widely used to restore disturbed circadian rhythms and to improve metabolic health in obesity, insulin resistance, metabolic syndrome, and cardiovascular diseases. In the best way, TRE approach has to be used in combination with healthy dietary composition, an increased physical activity, and adequate sleep quality and duration to support optimal health. However, future carefully controlled TRE studies are needed to formulate dietary recommendations for the general population and medical practice.OP-R generated the idea and performed the supervision of the manuscript preparation. All authors contributed to the article and approved the submitted version.The study was supported by a grant of the German Science Foundation (DFG RA 3340/3-1 OP-R), of the German Diabetic Association , and by the Morgagni Prize of the European Association of Study of Diabetes 2020 (OP-R).The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


The Malayan tiger, with less than 200 individuals in Malaysia, is in an intermediate population crash. Anthropogenic disturbances , environmental perturbation , and infectious diseases have been identified as factors leading to impending extinction. Preliminary findings from stakeholders indicate Peninsular Malaysia has an existing Malayan Tiger conservation management programme. However, to enhance the protection and conservation of the Malayan Tiger, the authority should re-assess the existing legislation, regulation, and management plan, and realign them to prevent population decline.Panthera tigris jacksoni), with an estimated population of less than 200 individuals left in isolated rainforest habitats in Malaysia, is in an intermediate population crash leading to extinction in the next decade. The population has decreased significantly by illegal poaching, environmental perturbation, roadkill, and being captured during human–wildlife conflicts. Forty-five or more individuals were extracted from the wild  in the 12 years between 2008–2019. The Malayan tigers are the first wildlife species to test positive for COVID-19 and are subject to the Canine Distemper Virus. These anthropogenic disturbances (poaching and human–tiger conflict) and environmental perturbation  have long been identified as impending extinction factors. Roadkill and infectious diseases have emerged recently as new confounding factors threatening Malayan tiger extinction in the near future. Peninsular Malaysia has an existing Malayan tiger conservation management plan; however, to enhance the protection and conservation of Malayan tigers from potential extinction, the authority should reassess the existing legislation, regulation, and management plan and realign them to prevent further population decline, and to better enable preparedness and readiness for the ongoing pandemic and future threats.The critically endangered Malayan tiger ( Panthera tigris jacksoni) is in an intermediate population crash leading to extinction in the wild by the next decade. It is estimated that less than 200 individuals are left in fragmented and isolated rainforest habitats in Malaysia.The critically endangered Malayan tiger , environmental perturbation , trade in traditional Chinese medicine using illegal tiger products ,7,8, andThrough the Department of Wildlife and National Parks (DWNP), Malaysia’s Government has always placed top priority on Malayan tiger conservation. The DWNP recognised the Malayan tiger as a totally protected species and a critically endangered species, as published in the Malaysian mammals red list in 2017 .Regarding species conservation, Malaysia has started systematically implementing the national conservation initiative–the Malaysia National Tiger Conservation Action Plan (NTCAP) in 2009 with the intended goal to double the country’s tiger population from then 500 to 1000 by the year 2020 [Following the launch of the NTCAP in 2009, the Government of Malaysia, through the Department of Town and Country Planning (DTCP), followed up by establishing the Central Forest Spine (CFS): Master Plan for Ecological Linkages in 2010, the main objective of which is to create ecological linkages for environmentally sensitive areas. NTCAP has been used as the main reference to stimulate the establishment of the linkages. Meanwhile, the government also began the “Save the Malayan Tiger” campaign in 2018 for integrated conservation management planning, including the ex situ dimension. However, as Sanderson, et al.  mentioneTherefore, this paper aims to present the tiger’s current conservation status and examine the tiger’s likeliness for impending extinction while impacted by anthropogenic disturbances due to environmental perturbation and recent zoonotic diseases.We screened documents and internal annual reports from the Department of Wildlife and National Parks (DWNP) Malaysia. We conducted and analysed questionnaires from selected captive tiger facilities that housed captive Malayan tigers.Based on available datasets, we interpreted the anthropogenic activities of the tropical lowland habitats, the impact of human–tiger conflict, and the roles of captive breeding to provide new insights for future global strategies for the management and perpetual conservation of this majestic critically endangered species for our next generation.Panthera tigris jacksoni) Studbook which were extracted for this study [The questionnaire was carried out from December 2018 to June 2019. During the present study, we distributed 73 questionnaires through emails or handed the hardcopy to the potential respondents with various positions in the 48 known captive tiger facilities globally and ten captive facilities in Malaysia that owned Malayan tigers. The zoos’ records consist of the Malayan tiger captive population based on datasets from the Department of Wildlife and National Parks (DWNP) Malaysia and the Malayan tiger .The type of sampling approach applied was a cross-sectional sampling survey and involved data collection at one point in time . This stThe instrument was developed using both “closed-ended” and “open-ended” techniques using the 1–5 Likert scale to allow the respondents to give a value for their opinions. The questionnaire was written in English and divided into five sections .Section A contained the respondent’s background with six questions about demographic details such as name, gender, education level, the field of expertise, the subfield of expertise, and the number of working years in the conservation field.Section B contained the institution’s background. This Section had five questions: name of the institution, the number of wildlife species kept in the institution, institution category, and the respondents’ position in the institution.Section C regarded animal captive management, and the questionnaire focussed on the origin and background of the Malayan tiger. The items regarded the animal population’s initial sources, the number of years the institution had housed the animals, and the purpose of the institution’s captive programme. Regarding the 89 questions in section C, the items were specifically designed to collect information and opinions on the species’ captive animal management. Most of the questions were close-ended questions except for two open-ended questions. The open-ended questions enabled the respondents to give their opinions on any other domains and items essential for the animal species and captive conservation management.Section D regarded animal ex situ management and contained 33 questions to gather expert opinions on animal ex situ management. Regarding the ex situ conservation efforts for the species, the author also provided 15 questions to explore the estimated amount of cost to the institution for the particular animal species. This section also had one open-ended question to enable the respondents to list any other domains in which their opinions were important in the ex situ species management.Last, section E was for general comments; five open-ended questions inquired about the respondents’ general comments and views regarding animal conservation management.The questionnaire was designed in the simplest and most informative way to avoid misunderstandings, confusion, or bias amongst respondents. Some of the questions needed the respondents to give a rating based on the Likert 1–5 scale. The Likert scale required the respondents to agree or disagree with the statements on a five-point scale . ConsideThe data were coded and analysed using the Statistical Package for Social Science software programme . The percentage was used in representing the data .We also compiled the Department of Wildlife and National Parks (DWNP’s) annual reports, published reports, and wildlife conflict database from 2008 to 2019 and classified them into various categories.n = 30) from 14 captive animal facilities (29%) from 30 expert respondents. Out of the 14 facilities that gave a response, five were from Malaysia’s local captive animal facilities.The structured questionnaire was collected from 30 expert respondents , including 20 local zoo respondents from five facilities, regarding the current governance of the ex situ Malayan tiger management. Malaysia has ten facilities that own captive Malayan tigers, with eight in Peninsular Malaysia and one each in the States of Sabah and Sarawak. We received 30 completed (41%) questionnaires (The 30 expert respondents were from zoos (26 respondents) and rescue centers (4 respondents) comprising executive-level (4), administrative-level (5), veterinarian or husbandry curator (13), and supervisor (8) responsibilities. Sixteen percent of the respondents were Masters degree holders, 50% were first degree holders, 17% were diploma holders, and certificate holders were 17%.About 93% of the expert respondents agreed that it was important that scientific knowledge be integrated into the Malayan tiger conservation policy and practice . HoweverConsidering the survey, 52% of the respondents agreed that the institution must implement Malayan tiger strategic and management plans . To implWithin about seven decades of persecution and prime habitat loss ,23, the Considering the human–tiger conflict context, there were 652 cases of conflict recorded during 2008–2019. The yearly trend reveals that the number of conflict cases is decreasing. The conflict cases fluctuated from 86 cases per year in 2008 to 41 cases per year in 2019 .Viewing the data recorded from 2008–2019, the Department of Wildlife and National Parks (DWNP) has captured four conflict tigers and lost one tiger due to accidental roadkill. Malaysia also estimated that the country has lost approximately 39 tigers to illegal poaching from 2008–2018  Table 2Table 2.Between 2008–2019, there were 99,954 cases of human–wildlife conflicts recorded in Malaysia, 652 cases involved the Malayan tigers .Regarding Peninsular Malaysia, there were 3386 cases of roadkills in nine years (2011–2019). The State of Johor recorded the highest roadkill numbers with 702 cases and the lowest recorded was one case in the Federal Territory .The government of Malaysia provided RM2.5 million to purchase land for corridors, habitat, rehabilitation, signs, road repairs, monitoring, and equipment . The totRhinoceros sondaicus) in 1932, the Banteng (Bos javanicus) in the 1950s, and the Sumatran rhinoceros (Dicerorhinus sumatrensis) in 2020 in Peninsular Malaysia [Over the past eight decades, Malaysians witnessed the extinction of the Java rhinoceros  and the barking deer (Muntiacus muntjac) until 2021 [The in situ conservation policy of tiger conservation is well developed. Malaysia’s National Tiger Conservation Action Plan (NTCAP) is among the earliest comprehensive tiger actions in the region. The protection of forest habitat and the protection of tiger-prey species are among the actions enlisted in the NTCAP. Malaysia recognised the importance of the protected areas in biodiversity conservation and protection. All tiger habitats may be considered protected under the Wildlife Conservation Act (WCA) 2010 as part of the in situ conservation efforts, subject to agreements with the tiger range States within the Federal Constitution’s determinations. To secure the tiger prey species, Malaysia has issued a hunting moratorium on two main tiger prey species—the Sambar deer   to be foThe Malayan tiger is listed under the Convention of International in Endangered Species of Wild Fauna and Flora (CITES). The CITES is an international agreement between governments to provide a sustainable international trade platform . RegardiThe gazettement of Act, Enactment, and Ordinance in Malaysia has provided protection and conservation for the tiger ,43. HoweAlthough studies show that the eco-certified logging concession in Peninsular Malaysia can preserve some of the threatened mammal species , loggingThe animals will cross the road either for water, food, shelter, mates, or nesting sites, but road networks and fast-moving traffic have become dangerous. Roads and fast-moving traffic have killed a lot of wildlife, leading to local population losses ,51,52,53During 2019, canine distemper disease infected the Malayan tiger, and the infectious disease may threaten the tiger population . MalaysiThe present research on tigers uses labour-intensive methods by counting and comparing tracks of vital activities (counting direct or indirect signs) ,64 and uWe distributed the questionnaire before the emergence of the COVID-19 pandemic. The questions in the survey were mostly designed from the standard for animal ex situ management. We were aware that the questionnaire feedback was limited. There are 48 captive animal facilities globally, and ten facilities in Malaysia that own Malayan tigers. We attempted to reach out to all the facilities but only managed to gather responses from 14 facilities with 30 respondents. This study provides an early indication of ex situ Malayan tiger management as a basis for an expanded questionnaire study.The habitat protection, sustainable financing, inclusive species policy, strategic plan, and action plan in situ and ex situ are the essential ingredients for successful Malayan tiger survival to avert possible extinction. Aside from managing the wild and captive populations, Malaysia needs to address the threat of infectious disease (canine distemper and COVID-19) to the Malayan tiger. Malaysia’s wildlife authority needs to move swiftly to protect and avoid the critically endangered Malayan tiger from being infected and falling into the COVID-19 chain. The Malayan tiger conservationists need to continue collaborating, supporting, and co-managing its ex situ management as part of assisting and increasing its wild Malayan tiger population. Malaysia needs to set an integrated strategy for sustainable conservation of all the wildlife, including the Malayan tiger as a keystone species. Additionally, the authority also could explore, modify, and adapt the Giant Panda conservation model’s sustainable financing mechanism. The Giant Panda conservation efforts to bring the species back from extinction risk have proved that its conservation model is successful and workable ,70.Malaysia is working toward the United Nations Sustainable Development Goals (SDGs), designed to end poverty, protect the planet, and ensure that all people enjoy peace and prosperity by 2030 and achieve the SDG 15. The SDG 15′s goal is to protect, restore, and promote sustainable use of terrestrial ecosystems, sustainably manage forests, halt and reverse land degradation, and halt biodiversity loss. Future research should identify potential sites for reintroduction of Malayan tigers in protected areas. Alternatively, intensive management of the wild population could be established in an electrified fenced area. These areas could ensure the biosecurity of the genetic pool could be closely monitored while effectively controlling the biosafety against emerging infectious diseases or pandemic.


To assess the individual and community health effects of task shifting for emergency care in low-resource settings and underserved populations worldwide.We systematically searched 13 databases and additional grey literature for studies published between 1984 and 2019. Eligible studies involved emergency care training for laypeople in underserved or low-resource populations, and any quantitative assessment of effects on the health of individuals or communities. We conducted duplicate assessments of study eligibility, data abstraction and quality. We synthesized findings in narrative and tabular format.Of 19 308 papers retrieved, 34 studies met the inclusion criteria from low- and middle-income countries (21 studies) and underserved populations in high-income countries (13 studies). Targeted emergency conditions included trauma, burns, cardiac arrest, opioid poisoning, malaria, paediatric communicable diseases and malnutrition. Trainees included the general public, non-health-care professionals, volunteers and close contacts of at-risk populations, all trained through in-class, peer and multimodal education and public awareness campaigns. Important clinical and policy outcomes included improvements in community capacity to manage emergencies (14 studies), patient outcomes (13 studies) and community health (seven studies). While substantial effects were observed for programmes to address paediatric malaria, trauma and opioid poisoning, most studies reported modest effect sizes and two reported null results. Most studies were of weak (24 studies) or moderate quality (nine studies).First aid education and task shifting to laypeople for emergency care may reduce patient morbidity and mortality and build community capacity to manage health emergencies for a variety of emergency conditions in underserved and low-resource settings. Conditions that could be treated with prehospital and emergency care account for an estimated 24 million lives lost each year in low- and middle-income countries.,International guidelines define first aid as “initial care provided for an acute illness or injury” or “help to a suddenly ill or injured person which is initiated as soon as possible and continued until that person has recovered or medical care is available”.–Laypeople with training in first aid can improve access to care for underserved populations, and often deliver the only emergency health-care services in low-resource settings.The purpose of this systematic review was to identify the individual and community health effects of task shifting for emergency care in underserved populations and low-resource settings. We hoped to guide programme developers and policy-makers towards interventions that had been subject to evaluations with demonstrable health effects, and to help researchers and evaluators to understand and optimize these initiatives.,We developed, registered and published a systematic review protocol based on the PRISMA  Statement (PROSPERO CRD42014009685).We designed the research question for the review according to the Population, Intervention, Comparator, Outcome, Time (PICOT) framework.Box 1Underserved or low-resource population: A group that faces any barrier to accessing organized prehospital emergency medical services, including geographical, financial, occupational, sociopolitical, ethnocultural, infrastructural or informational barriers.,,Emergency health condition: Health problem(s) where treatment should occur within minutes or hours to reduce suffering, morbidity or mortality. Task shifting for routine intrapartum and perinatal care has been reviewed systematically elsewhere and we therefore excluded it from our definition of emergency health conditions.,,First aid or prehospital emergency care: Any effort to identify, care for or treat an emergency health condition in a prehospital or out-of-hospital setting. First aid may be definitive care or may involve transition to more advanced care.Training or education: Any effort intended to confer knowledge or skills to a person, or change their attitudes and behaviours.Laypeople trainees: Any community member who has no health professional designation or certification and who is not primarily employed in health-care delivery. This definition of laypeople excludes paraprofessional cadres such as community health workers, where emergency care formed part of the workers’ practice.Individual or community health effects: Any quantified effect on morbidity, mortality or community capacity to manage a health problem. We considered willingness to provide emergency care as a health outcome when measured at the community or population level and not when measured only among trainees.We developed a search strategy to identify papers addressing first aid or prehospital emergency care by laypeople. We used a sample set of relevant articles to evaluate the recall and precision of search terms and refine our search strategy.We searched the following databases: MEDLINE®, Embase®, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Scopus, SocINDEX, PsycINFO, Education Resources Information Center (ERIC), Cochrane Database of Systematic Reviews (CDSR), African Index Medicus (AIM), Index Medicus for the WHO Eastern Mediterranean Region (IMEMR), Latin American and Caribbean Health Sciences Literature (LILACS), Index Medicus for South-East Asia Region (IMSEAR) and Transport Research International Documentation (TRID). We adapted our search for grey literature using keywords that targeted the websites of humanitarian and global health agencies, academic grey literature databases, theses and dissertations, clinical trials registries and conference proceedings.,,–We also scanned the references of all included studies and manually searched references of first aid guidelines and reviews from the American Heart Association and the American Red Cross, European Resuscitation Council and International Liaison Committee on Resuscitation.κ >  0.61) between reviewers.We trained an international team of 18 reviewers with varied expertise in the subject matter and methods of the review, using a video to familiarize them with the research question and inclusion criteria. All reviewers screened a test set of 70 papers selected from our search that included seven papers that met enough inclusion criteria to proceed to full-text review. We conducted an internal study on this test set to confirm substantial interrater agreement , outcomes  and key conclusions. Where multiple publications reported on the same underlying study, we extracted data from all related papers and reported results from the most definitive paper.We performed independent and duplicate assessment of study quality, including internal and external validity, selection and measurement biases, and confounding factors, using the Effective Public Health Practice Project quality assessment tool.We prepared a narrative and tabular synthesis of our findings. We grouped studies qualitatively according to the illnesses or conditions addressed, the role of lay providers, the type of educational intervention provided and the type of outcomes reported. We distinguished individual health outcomes such as survival to hospital discharge; community health outcomes such as all-cause mortality; and measures of community capacity to manage emergencies such as cardiac arrest response times. Our rationale for these groupings was first to underscore the emergency health conditions for which studies had been identified, and then to provide information to guide future task shifting and first aid training interventions. We drew on Cochrane Collaboration guidance on syntheses without meta-analysis to assess the risk of bias across studies, and considered the number of studies, consistency of effects and directness of findings to develop plain-language summary statements of the effects of interventions.κ = 0.75).Our database searches yielded 19 308 unique papers. We retained 415 papers for full-text review, resulting in 43 eligible papers from 34 unique studies . Grey lihttp://www.who.int/bulletin/volumes/99/7/20-270249) summarizes the studies that met the inclusion criteria, grouped by emergency medical condition, including cardiac arrest (four studies),–,–––––,,,,,–,,,,,,,,–,,,,,Most studies used observational or quasi-experimental designs, including 11 uncontrolled before-and-after studies,,–,––, ,–,,The populations studied included rural, urban and underserved subpopulations from North America, Europe, Asia, Africa and Australia and Oceania. Sample sizes ranged from under 300 people to population-based studies of over 5 million people . Table 2The included studies described a variety of educational approaches, including public campaigns (three studies), in-class training programmes (17 studies), peer or individual training (seven studies) and multimodal training programmes (seven studies). A total of 33 studies assessed targeted interventions addressing priority emergency health conditions in the given population, such as opioid poisoning among people who use drugs or trauma management in regions with an elevated incidence of trauma from landmines. One study assessed a comprehensive training initiative designed to enhance responses to diverse conditions among Indigenous hunters and trappers in remote Canada .65,,,,Trainees included the general public (five studies), non-health-care professionals such as drug retailers and flight attendants (five studies), community volunteers (10 studies) and family members and close contacts of at-risk populations such as people who use opioids or children at risk of malaria , as sole providers with responsibility for transferring selected patients to other professionals (20 studies), or as responders in a community chain-of-survival involving routine patient transfer to other providers , while 13 studies reported on individual health and seven reported on community health outcomes .Most studies reported small effect sizes . Some stTwo included papers reported null or equivocal results. A cluster randomized controlled trial of a malaria education and management programme for women’s groups observed no effect on the prevalence of severe malaria-associated anaemia in children.,,,We found that first aid education and task shifting to laypeople may reduce morbidity and mortality, and enhance community capacity to manage health emergencies for a variety of emergency conditions. The studies include cardiac arrest, burns, malaria, malnutrition, opioid poisoning, paediatric communicable diseases, snakebites and trauma. All of the included studies evaluated targeted training for priority local emergency conditions; there were no eligible studies concerning courses with general, untargeted first aid curricula. The overall weak quality of studies in our review underscores the limitations in the available science, the need for rigorous studies in this field, and the challenges inherent in evaluating complex population health interventions such as task shifting.,,Previous reviews demonstrate the effectiveness of first aid education by reporting on knowledge, skills, helping behaviours or confidence among trainees.Like other task-shifting strategies, first aid education is a complex, system-level intervention that requires its own foundation of evidence.Our review advances novel conceptual ties between first aid and task shifting. Lay emergency care and volunteer paramedic interventions are among the most cost-effective ways to reduce avoidable mortality worldwide, but unlike other task-shifting interventions, first aid has not been widely characterized or evaluated based on broad public health impacts.We have summarized the breadth of contexts and conditions where lay responders, bystanders or friends and family can provide first aid. Leading international guidelines define first aid as “the initial care provided for an acute illness or injury” that “can be initiated by anyone in any situation.”,The strength of this review is its breadth, including a search of multiple databases and inclusive search terminology to synthesize the wide range of experimental and observational research concerning task shifting for emergency care in low-resource and underserved settings worldwide. By training and assessing interrater reliability of an international team of reviewers we were able to achieve a manual review of over 19 000 studies. Our approach to populations including both low- and middle-income countries and underserved subpopulations in high-income countries is a conceptual strength aligned with global approaches to health equity.In conclusion, first aid for laypeople may have its greatest impact when approached as a series of targeted interventions that equip the public to respond to the health emergencies that they are likely to encounter in their everyday lives and communities. More work is needed to orient first aid education to deliver the greatest effects on patient and community health, and to identify the modalities that are best suited to specific contexts, populations, clinical conditions and public health priorities. Task shifting to laypeople for emergency care may save lives, reduce morbidity and enhance community capacity to address acute health problems in low-resource settings.


Motor vehicle crashes (MVC’s) in the American Indian/Alaska Native (AI/AN) communities account for 43% of unintentional injury deaths. This article introduces MVC data and geographic information system (GIS) mapping for tribal reservations.Utilizing a sample of Montana Department of Transportation (DOT) data for the Flathead reservations to calculate frequencies and proportions of crash types , while also mapping these data to provide a cross-sectional snapshot of MVC’s.Overall, 515 MVC’s occurred for years 2016 through 2018, with no-injury, injury, and fatality accounting for 72.2%, 24.9% and 1.8% of all crashes, respectively, with the number of MVC’s ranging up to 30 per square mile.Examining DOT data and utilizing it for visual representation of MVC’s can be used as an additional source in uncovering patterns and trends on Tribal reservations and supporting MVC prevention efforts. Motor vehicle crashes (MVCs) are one of the leading causes of death in the USA and account for 43% of all unintentional injury deaths among American Indian/Alaska Native (AI/AN) communities (Centers for Disease Control and Prevention (CDC) 2020; Indian Health Service The IHS has focused much of its work and data on general epidemiology and clinical outcomes, with little information being gathered on geospatial displays and risk factors.State Departments of Transportation (DOTs) have highlighted the importance of having comprehensive crash maps as critical components of safety data management and highway safety plans. Similarly, MVC maps can assist Tribal governments, programs, stakeholders and partners in identifying hot spots of high risk roadways, crash severity and contributing risk factors to inform policy, program planning, and evaluation  methods to demonstrate the potential value of geographic visualization as a highway safety tool for tribal reservations.We used existing data and descriptive techniques to accomplish the study aims.We examined a sample of MVC on the Flathead reservation within Montana.We obtained MVC data through requests submitted to the Montana DOT for years 2016 through 2018, the most recent years available. Records were included in the study only if the crash occurred on the reservation property and within the boundaries of Flathead, Lake, Missoula or Sanders counties. Person-level data only included motor vehicle occupants and excluded pedestrians or other individuals. The population studied was inclusive of AI/AN only, which were selected using the Race variable as originally recorded in source documents.Injury variables in the original DOT dataset were combined to derive the variable Crash Type with three categories: no-injury, injury and fatality Table  for descFrequencies and proportions for MVCs by the variable Crash Type. Some data were missing for the variable Crash Type and were therefore excluded for the purposes of this study. All statistical analyses were performed using SAS 9.4.http://www.esri.com/software/arcview/index.html), using the XY (latitude/longitude) coordinate variable, to provide a cross-sectional snapshot of MVCs related to Crash Type within the Flathead Reservation. The mapping process begins with a base map that includes layers showing interstate highway systems, major state highways and local roadways, upon which displays of individual crash points and thematic groupings were overlaid. Additional data presented on the maps include summary variables such as the number of injuries per crash.To map the data, we used ArcMap  were created with the cell width and height set to 1-mile by 1-mile area, corresponding to specific regions of each reservation. Crash variable attributes corresponding to the gridded shapefiles were summed and then thematically displayed in square mile polygons to include the number of MVCs that have occurred within each polygon.During the years 2016 through 2018, there were 515 MVCs involving AI/AN people on the Flathead reservations, being mapped to identify clusters of data.More than half 72.2%) of all the MVCs resulted in no-injury, with injury and fatal MVCs accounting for 24.9% and 1.8%, respectively , to support tribal safety and obtain funding for road improvement projects  and other variables provided in DOT data, such as the number of injuries or fatalities per crash and environmental factors at high MVC frequency locations, provide multiple avenues for future scientific inquiry.This study has several limitations and serves primarily as an introduction to data and mapping for tribes. Due to the vast uses of DOT data and GIS mapping, this study was limited to expanding on additional data, variables and map displays. The quality and completeness of DOT data from reported crashes may include inaccuracies due to missing data , incorrect or inaccurate crash location information, poor base maps, and limited resources and techniques for crashes off state roadways (Qin et al. The goal of this study was to apply GIS techniques to MVC data as an introduction to the value of geographic visualization as another means to support epidemiological and clinical outcome research used by IHS in support of MVC safety on reservations locally and nationally.Data sources containing valuable information, such as DOT crash data and others, can be considered when investigating MVCs on Tribal reservations in addition to data currently being used. Furthermore, utilizing GIS for MVC’s and other events can assist in uncovering patterns and trends in injury morbidity and mortality, providing both visual impact and data analysis simultaneously. This can lead to confirmatory and explanatory data solutions to a variety of highway safety questions beyond the traditional research and statistical methods previously utilized by tribes.