In 2014, the Centers for Disease Control and Prevention (CDC) commissioned the Urban Indian Health Institute (UIHI) to coordinate a multifaceted national evaluation plan for Good Health and Wellness in Indian Country (GHWIC), CDC’s largest investment in chronic disease prevention for American Indians and Alaska Natives (AI/ANs). GHWIC is a collaborative agreement among UIHI, CDC, tribal organizations, and individual tribes. In collaboration, UIHI and CDC drew upon an indigenous framework, prioritizing strength-based approaches for documenting program activities, to develop a 3-tiered evaluation model. The model incorporated locally tailored metrics, adherence to tribal protocols, and cultural priorities. Ultimately, federal requirements and data collection processes were aligned with tribal strengths and bidirectional learning was promoted. We describe how UIHI worked with tribal recipients, tribal health organizations, Tribal Epidemiology Centers, and CDC to develop and implement the model on the basis of an indigenous framework of mutual trust and respect. American Indians and Alaska Natives suffer disproportionate health disparities and chronic disease rates compared with other populations. To address disparities, a history of mistrust between tribal communities and the federal government regarding evaluation and other data-driven practices must be confronted.We describe an Indigenous Evaluation Framework, emphasizing indigenous core values and knowledge, used to evaluate a federally sponsored initiative to prevent chronic disease in Indian Country.Our work improves public health practice by reinforcing how indigenous ways of gathering knowledge are as valid and effective as Western methods.Reframing Evaluation: Defining an Indigenous Evaluation Framework, “The field of evaluation draws heavily on research methodologies that can be considered invasive when imposed by outside funding agencies” (The Centers for Disease Control and Prevention (CDC) launched Good Health and Wellness in Indian Country (GHWIC) in 2014 to reduce American Indian and Alaska Native (AI/AN) health disparities, including commercial tobacco use, obesity, and disability and premature death as a result of diabetes, heart disease, and stroke. GHWIC sought to build an overall evaluation plan by using an indigenous framework to match the locally tailored, culturally driven program approach. Historically, research and evaluation efforts have abused and exploited AI/AN communities, such as in the 1979 Barrow alcohol study that published negative reports about Inupiaq villages without consulting those communities  share successes and lessons learned across Indian Country and beyond, 2) report outcome data to GHWIC communities for feedback and guidance on program implementation and improvement, 3) expand the evidence base for chronic disease prevention in Indian Country, and 4) support opportunities for future funding to promote AI/AN community health programs.GHWIC recipients include 12 federally recognized tribes and 11 tribal health organizations (THOs) that serve tribes in their Indian Health Service (IHS) service regions. The program operates at 3 interconnected levels: local communities (tribes), regions , and nationally (Indian Country-wide). The evaluation approach mirrors this program design with the Urban Indian Health Institute (UIHI) focusing on all AI/AN communities served and supporting all GHWIC recipients. CDC supports GHWIC recipients and provides data on GHWIC national outcomes, accomplishments, challenges, and progress.The framework for the GHWIC initiative and evaluation approach began to take shape as early as 2011 when CDC’s tribal advisory committee — a federally mandated committee to advise CDC on tribal matters — encouraged CDC’s National Center for Chronic Disease Prevention and Health Promotion (NCCDPHP) to more thoughtfully address serious health disparities among AI/ANs while respecting and incorporating indigenous knowledge. As a result, NCCDPHP staff participated in the first CDC listening sessions with tribal health leaders and visited tribes and tribal organizations over several years before launching the GHWIC initiative. In these sessions and visits, tribal partners offered knowledge and wisdom to CDC staff on how federal funding does not take the AI/AN perspective into account and how tribes and CDC could work together. These activities helped to expand the Western approach to understanding health and disease and how to track progress toward improving health by integrating cultural values of indigenous communities. A key discussion point was the importance of identifying principles of program development and evaluation processes with the people and organizations served by CDC funds. CDC’s understanding continued to evolve during the GHWIC program period, from 2014 through 2019, as recipients and CDC struggled with conflicting demands of meeting AI/AN cultural imperatives and required deliverables. Through collaboration, listening, and learning, GHWIC was eventually able to develop culturally sound programs and evaluation approaches tailored to specific indigenous cultural customs and tribal protocols.The Indigenous Evaluation Framework describes the following 4 core values that were adapted by the GHWIC model  3)::3):Centrality of the Community and Family requires engaging the community when planning and implementing an evaluation, making evaluation processes more transparent, and highlighting the importance of community health in addition to individual achievements.People of Place recognizes a tribal entity’s relationship to land and history, how historical events have shaped current health conditions, and the uniqueness of place and history. What occurs in one place might not be generalizable to other situations or other locations.Recognizing Individual Gifts prompts evaluators to take a holistic approach to evaluate while acknowledging that there are different ways of conducting evaluation.Upholding Personal and Tribal Sovereignty embodies respect for tribal approval processes, building greater capacity within recipient communities and reporting findings in ways that are meaningful and impactful to recipients.Integrating these values required federal partners and public health professionals to recognize the importance of culture in AI/AN health. Cultural centrality and mutual respect were critical to effectively implement the GHWIC initiative and its evaluation. The indigenous framework emphasizes the criticality of local context and community knowledge in documenting program gaps and successes. To accomplish federal goals while aligning data processes with tribal recipient values, GHWIC established a systematic approach to promote bidirectional learning for both program and evaluation implementation. Technical assistance (TA) was provided to recipients through the Evaluation TA Exchange Partners (EEPs) model. The EEPs model involved members of the GHWIC evaluation team, which included CDC and UIHI staff, to provide ongoing, one-on-one support to recipients throughout the cooperative agreement. EEPs were matched with recipients, based on outcomes, geography, and staffing capacity and worked with recipients through video conferences, site visits, and ad hoc communications to share guidance on evaluation plans, performance measurements, and annual report development.Indigenous methods coupled with community-based participatory approaches emphasize transparency, equitable partnerships, and actionable objectives to promote sustainable change for improved health outcomes. Evaluation efforts that include community participation in the design, development, and implementation are more likely to effectively document long-term change and program gaps . UIHI anThe 3-tiered model  was deveIn the early stages of the GHWIC initiative, UIHI, CDC evaluation staff, and recipient representatives identified a series of performance measures and evaluation outcomes that would contextualize GHWIC efforts, identify successful activities, and provide lessons learned for others supporting similar tribal health promotion programs. With these metrics, UIHI and CDC compiled findings and created reports documenting the regional and national impact of GHWIC. For example, aggregated data show that from 2014 through 2017, approximately 15,000 AI/AN people had better access to healthier foods through 16 new tribal settings with low sodium nutrition guidelines and 77 new tribal settings promoting nutritious foods (The GHWIC indigenous framework placed recipient (Tier 1) knowledge at the forefront of developing effective and sustainable health interventions in tribal communities for a true reflection of the impact of those interventions. Implementing the 3-tiered evaluation model offered UIHI the ability to measure impact through an indigenous lens with collaborative decision making and bidirectional learning among tribal and federal partners. At the local level, recipients established evaluation indicators that best reflected the qualities of their cultural and community landscapes. At the regional level, THOs and TECs developed strong partnerships and trust with tribes in their regions, allowing them to collect and analyze local and regional data. Data from these 11 regions were then combined to assess national impact. However, the GHWIC evaluation had limitations. Because of the flexibility in performance measure selection, methods for data collection varied, making aggregate data assessment inclusive of all recipient activities difficult. In addition, not all tribal communities in the United States were represented in the GHWIC initiative. Despite these shortfalls, the GHWIC evaluation model provided an important framework for a tribal-CDC partnership to achieve increased AI/AN health and wellness.


Bordetella pertussis (BP) infection , a ratio of up to 1,400 subclinical BP infections for every reported pertussis case.Subclinical BP infections are vastly more prevalent than reported pertussis  has been associated with febrile seizures (but not epilepsy) (Barlow et al., As subclinical BP colonizing infections are prevalent in highly BP-vaccinated populations, and non-human primate studies demonstrate the failure of DTP and DTaP to prevent nasopharyngeal BP colonization (Warfel et al., In light of the available evidence, we suggest that a causal role for subclinical BP colonizing infection in epilepsy is plausible and worthy of further investigation. Regression analysis of epilepsy risk, incorporating BP screening assays, medical history, and pertussis vaccination status would be a compelling first step in assessing the potential relationship between epilepsy and subclinical BP infection.KR and SG contributed equally to the preparation of this manuscript.Bordetella pertussis. ILiAD Biotechnologies had no role in the study design, analysis, and development of this opinion submission.KR and SG are employed by and hold an equity interest in ILiAD Biotechnologies, which is developing a vaccine for the prevention of


Ending AIDS as a public health threat while aiming for universal access to Sexual Reproductive Health (SRH) remains a dual strategic goal of both HIV/AIDS and SRH programming. Advancing this goal across the two programming areas will require deliberate interventions to connect implementation at policy, systems, funding, coordination, management, service delivery and monitoring levels.In 2017, Sub-Saharan Africa was home to 25.6 million people living with HIV . This reAdditionally, sub-Saharan Africa has a low modern contraceptive prevalence rate estimated at 28% . The jouSince the 2004 Glion Call to Action on the linkage between FP and Prevention of Mother-to-Child Transmission of HIV (PMTCT), several initiatives and policies have been put in place to facilitate SRH and HIV integration . What coDespite insufficient data to fully evaluate the effect of SRH and Rights (SRHR)/HIV integration on unplanned pregnancies comparing outcomes from integrated to non-integrated sites, several studies demonstrated reduction in costs for service delivery, increased client knowledge, and increased use of modern contraceptive methods  . To realReproductive Health and BMC Public Health examines the integration of SRH and HIV/AIDS from different perspectives. From the integration of family planning as a second prong of the prevention of vertical transmission of HIV including among female sex workers, to the concept of safer pregnancy in HIV-affected individuals, through the integration of SRH in the minimum package of HIV prevention, care and treatment. The articles also examine the design of innovative approaches for integration in community-based service delivery models. Defining success in service integration has been elusive and the experiences shared in these articles cut across several countries and geographic focuses including in Botswana, Cameroon, Kenya, Malawi, South Africa, Tanzania, Uganda and the United States. Additionally, one systematic review and one literature review explore respectively the specific issue of integration of HIV testing into family planning and the issue of integration of Adolescents and Young Women SRH in emergency settings.A compilation of articles published in Effective integration of HIV and SRH services requires not only behavioral change interventions for health care providers  but also increased understanding of beneficiaries to respond adequately to their needs based on their knowledge, attitude, and risk perception. As demonstrated by González, Kadengye & Mayega, 2019) in their nationally representative household survey focused on young Ugandans, high levels of SRH/HIV knowledge and risk perception did not curb risky sexual behaviors despite the context of generalized HIV epidemic . The authors asserted that effectiveness gaps in the integrated SRH/HIV response should be addressed holistically at individual and structural level [ in theirA marginalized group among key populations in Sub-Saharan Africa, women who inject drugs, received attention in this supplement. Sylvia Ayon et al. 2019) used action research to identify the process, impacts, and challenges of integrating SRH into community-based HIV prevention and harm reduction programs in coastal towns in Kenya. Their findings highlight low utilization of family planning and other SRH services, and provide critical insight on the acceptability and opportunities for successful integration at community level [ used actA cross sectional study conducted in Kenya by Raymond Mutisya et al. assessed the level of integration of family planning across six other services delivery areas . Their findings validate what has already been documented on the positive correlation between provider knowledge, skills and attitude and service quality .A systematic review of the integration of HIV testing services into family planning services by Narasimhan et al. (2019) revealed that HIV counselling and testing was generally higher in integrated sites as compared to non-integrated sites, including in adjusted analyses through outcomes varied slightly across studies. Similar to Kiersten Johnson et al. findings, this review concludes that global progress and success for reaching SRH and HIV targets depends on progress in Sub-Saharan Africa where women bear a high burden of both unintended pregnancy and sexually transmitted infections, including HIV .In a 2015 State of the World Report, UNFPA stated that the many crises, wars, and natural disasters around the globe, and especially in Africa, are leaving women and adolescent girls facing a significantly heightened risk of unwanted pregnancy, maternal death, gender-based violence, and HIV acquisition. It is only befitting that this supplement includes a literature review by Roxo, Walker, Mobula, Ficht & Yeiser, (2019) on prioritizing the SRH and rights of Adolescent Girls and Young Women (AGYW) within treatment and care services in emergency settings. Their review revealed that the plurality of competing needs in emergency settings crowds out dedicated time and space to effectively integrate HIV and SRH interventions and that greater political will is required to advance the integration agenda [Two of the supplement’s articles discuss key findings on the availability of family planning and HIV-related integrated services in Sub-Saharan Africa, with one addressing the quality component. Studies by Kanyangarara, Sakyi & Laar, (2019) and Barden-O’Fallon, Mejia & Close, (2019) restricted analyses to health facilities offering HIV/AIDS care and support, not just HIV testing and counseling, and FP services. Using secondary analysis of Service Provision Assessments (SPA), Service Availability and Readiness Assessments (SARA) (2012–2015) for 10 countries including six in West and Central Africa), Kanyangara et al. found that 93% of facilities offering HIV care and support services also reported offering integrated services, but merely 29% were classified as having onsite integrated FP services based on the availability of structural and process of care inputs . Further, 94% of facilities reported routinely offering FP counselling to HIV/AIDS clients and 80% had three or more contraceptive methods in stock at the time of the surveys , 22.Matching SPA measures and a Quick Investigation of Quality indicators for FP quality in integrated compared with non-integrated lower-level HIV/AIDS care and support facilities in Malawi (2013–2014) and Tanzania (2014–2015), Barden-O’Fallon et al. found that 79% of facilities in Malawi and 38% in Tanzania offer FP services. In keeping with the Bruce/Jain Framework of Quality Care, 22 quality indicators were analyzed and showed integration status was significantly associated with three indicators for Malawi: “facility has all (approved) methods available: no stock outs”, “facility has received a supervisory visit in the past 6 months”, “look and write on client record”. For Tanzania the indicators associated with integration status were “facility has adequate storage of contraceptives and medicines”, “facility has all (approved) methods available: no stock outs”, “waiting time acceptable (negative)”, and “facility has mechanisms to make programmatic changes based on client feedback” .Two of the articles reviewed the knowledge and use of safer conception methods (SCM) among HIV-infected individuals on how to accommodate their safer conception needs. Both studies by Gwokyalya et al. (2019) and Schwartz et al. (2019) highlighted the need for more education and making available different methods of SCM to people living with HIV. Of the 5198 number of women interviewed at the health facilities in Uganda, 74.1% had knowledge of SCM but the number decreases to 42% with those of knowledge of more than one method. The study also underscored the lack of the involvement of partners in serodiscordant relationships in the choice and intent to use SCM. They emphasized the lack of qualified staff to undertake some of the SCM such as sperm washing. The study highlighted the increasing challenges by individuals with HIV to fulfill their fertility desire and concluded that the knowledge and use of SCM among HIV+ women in care is low. Efforts to improve HIV status disclosure, integration of safer conception into FP and HIV services, and regional efforts to promote sensitization and access to safer conception can help to increase uptake of safer conception methods , 21.With its four-pronged approach, PMTCT prevents 90% of new HIV infections among children and thus contributes to the AIDS-Free Generation. PMTCT is also at the crossroad of antenatal and postnatal care services, FP, and HIV prevention care and treatment services. Three manuscripts in this supplement address the issue of PMTCT through the lens of antenatal, HIV, and sexual and reproductive health services integration. The authors, Rwema et al. (2019), and Parmley et al. (2019), assessed the PMTCT cascade and investigated factors influencing antenatal care services seeking behavior in a context of high HIV prevalence among female sex workers (FSW) in Port Elizabeth, South Africa , 11.Rwema et al.(2019) found that 61% of FSW were infected with HIV and 52% of them knew their HIV status before the study. A gap of 40% was found regarding the systematic use of condoms by non-HIV-infected FSW with their clients and a gap of 43% in the use of long-term modern contraceptive methods among FSW living with HIV. Parmley et al.(2019) found in a similar context in Port Elizabeth, South Africa, a late discovery of pregnancy (at 4 to 7 months) among FSW living with HIV and a 40% antiretroviral therapy coverage among them. The influencing factors identified were alcohol and psychoactive substance use, as well as dissatisfaction with past health care experiences , 11.Two manuscripts are respectively related to factors associated with early detection of HIV among children of HIV-infected FSW in Cameroon and partner notification in Botswana. In Cameroon, out of the 481 FSW interviewed in the study of Rao et al., 70% reported that none of their children under the age of 5 years had been tested for HIV. The factors influencing HIV testing of the children of HIV-positive FSW were antenatal services attendance , knowing HIV status , the character desired of the pregnancy  and higher education level . Partner notification and proper treatment of partners are essential elements for breaking the chain of transmission of sexual transmissible infections (STI) including HIV infection. The supplement includes one qualitative study done by A. Wynn et al. (2019), in Botswana. The study revealed that treatment of partners was late and most participants expressed a preference for notifying their STI to their partners at a health facility with support from the health workers. The authors concluded that important progress remain to be made along the four pillars of PMTCT especially among key populations such as FSW .Cervical cancer is one of the leading causes of cancer deaths in women especially in middle and low income countries. It is associated with persistent or high-risk (or oncogenic) types of human papillomavirus (HPV). Its prevalence is higher among certain vulnerable groups like people living with HIV. This supplement includes an original study on the feasibility in rural areas of Zimbabwe to integrate HPV screening within existing community-based HIV programming and immunization outreach services. Samples were collected at community level by trained community health workers. The collection was performed during scheduled outreach visits for antiretroviral medications and childhood vaccines. Community health workers explained how to perform the self-collection sample. The samples were then transferred to a health facility for analysis. This integrated community outreach model was accepted by the beneficiaries with an 82% participation rate .Ending AIDS as a public health threat and ensuring universal access to sexual and reproductive health are two key targets for Sustainable Development Goal (SDG) 3. The articles reinforce that as we journey towards 2030, integration of SRHR and HIV can play an important role in improving the health and well-being for all. As Narasimhan et al. remind us global progress and success for reaching the SRHR targets depend on progress being made in sub-Saharan Africa that has the highest burden of unintended pregnancies, STIs including HIV.Call to action to attain universal health coverage through linked SRHR and HIV interventions issued at the International AIDS Conference in 2018. This call emphasizes that for interventions to have the desired impact they need to meaningfully engage communities in the design, implementation and monitoring in order to meet the community’s needs.A key message emerging from the collection of articles is the need for the principle of bi-directionality to be applied in all SRHR and HIV interventions. These articles reinforce one of the key action points in the A common thread is that integration can only be effective if investments are made in building the capacity of health care workers, and ensuring that health facilities have the necessary infrastructure, are well equipped and have adequate commodities supply. It is also evident that integration efforts should include not only health facilities but also community outreach interventions.While the SDGs call on the global community to “leave no one behind”, efforts need to be redoubled to address the needs of key and vulnerable populations within the four prongs of PMTCT and adolescent girls and young women within treatment, and care services in emergency settings. This collection of articles demonstrates that bringing together SRHR and HIV will require deliberate interventions and political commitment that places the individual at the center of service delivery.A French translation of this article has been included as Additional file A Portuguese translation of this article has been included as Additional file Additional file 1:Translation of this article into French. (PDF 173 kb)Additional file 2:Translation of the abstract of this article into Portuguese. (PDF 451 kb)


Emerging technological advances hold potential for individuals and caregivers to help an aging population in the home or long term care settings and has the potential to alter workforce needs and potentially mitigate the rising workforce demand. The purpose of the proposed research was to research available technologies that may facilitate, replace, or enhance recruitment, training, and retention of the LTC workforce. This qualitative study included environmental scan and literature search identifying 62 companies meeting criteria for potential impact on the workforce. Categories included wearables, robots, sensors/alerts, health/social data collection and tracking, family/caregiver communication services, online care management, online worker training, and facility or home health staffing systems. Thematic analysis findings of telephone interviews with 12 national and international companies included: 1) most development focused on software rather than hardware, 2) company founders generally had a tech background and start up experience along with personal family caregiving experiences, 3) data collected in the home often did not connect directly to the health care team, 4) payment was generally out of pocket to individuals or facilities under subscription services or contracts 5) worker retention improved when system allowed better client to worker matching, more control over shift scheduling, and more efficient staffing. There was little rigorous research on the impacts for care and services or which will have the greatest potential impact on the workforce providing direct care. Reimbursement from federal and private payers is minimal to date yet demand for government payment may grow.


Cervical cancer is the most commonly diagnosed cancer among women in Zimbabwe; however; access to screening and treatment services remain challenged. The objective of this study was to investigate socio-demographic inequities in cervical cancer screening and utilization of treatment among women in Harare, Zimbabwe.Surveytogo software in an android tablet. Data was analyzed using STATA version 14 to yield descriptive statistics, bivariate and multivariate logistic regression outcomes for the study.Two cross sectional surveys were conducted in Harare with a total sample of 277 women aged at least 25 years. In the community survey, stratified random sampling was conducted to select 143 healthy women in Glen View, Cranborne, Highlands and Hopely communities of Harare to present high, medium, low density suburbs and rural areas respectively. In the patient survey, 134 histologically confirmed cervical cancer patients were also randomly selected at Harare hospital, Parirenyatwa Hospital and Island Hospice during their routine visits or while in hospital admission. All consenting participants were interviewed using a validated structured questionnaire programmed in p < 0.05) and those who never visited health facilities or doctors or visited once in previous 6 months (p < 0.05). Ninety-two (69%) of selected patients were on treatment. Women with cervical cancer affiliated to protestant churches were 68 times [95% CI: 1.22 to 381] more likely to utilize treatment and care services compared to those in other religions (p = 0.040). Province of residence, education, occupation, marital status, income , wealth, medical aid status, having a regular doctor, frequency of visiting health facilities, sources of cervical cancer information and knowledge of treatability of cervical cancer were not associated with cervical cancer screening and treatment respectively.Women who reported ever screening for cervical cancer were only 29%. Cervical cancer screening was less likely in women affiliated to major religions (This study revealed few variations in the participation of women in cervical cancer screening and treatment explained only by religious affiliations and usage of health facilities. Strengthening of health education in communities including churches and universal healthcare coverage are recommended strategies to improve uptake of screening and treatment of cervical cancer. Cervical cancer is the most commonly diagnosed cancer amongst women and accounts for 32% of all cancers in Zimbabwe yet it is preventable . At leashealth and well-being of himself and of his family, including food, clothing, housing and medical care and necessary social services”  more likely to utilize treatment and care services compared to those in other religions (p = 0.040). Province of residence, education, occupation, marital status, income , wealth, medical aid status, sources of cervical cancer information and knowledge of treatability of cervical cancer were not associated with utilization of cervical cancer treatment and care after controlling for household heads’ occupation, education and area of residence.Table This study investigated the socio-demographic inequities in uptake of cervical cancer screening and treatment among healthy women and those with cervical cancer aged at least 25 years old. Non-participation in cervical cancer screening was associated with affiliations to Roman Catholic, Protestant, Pentecostal and Apostolic sect religions. Healthy women who never visited health facilities or doctors or only visited once were less likely to screen for cervical cancer. Age, education, occupation, marital status, medical aid status, income , wealth, sources of cervical cancer information, having regular doctor and knowledge of treatability of cervical were not associated with uptake of cervical cancer screening services after controlling for confounders. Utilization of treatment for cervical cancer was positively associated with affiliation to Protestant churches. Province of residence, education, occupation, marital status, income , wealth, medical aid status, sources of cervical cancer information and knowledge of treatability of cervical cancer were not associated with utilization of cervical cancer treatment and care after controlling for household heads’ occupation, education and area of residence.The study of socio-demographic inequities of cervical cancer screening and treatment is an important research endeavour in the context of Zimbabwe and other similar contexts. In our study context, inequity is defined as unfair and systematic disparities in the usage of cervical cancer screening and treatment services by groups already disadvantaged with respect to health . We haveThis research found religious affiliations and usage of health facilities as determinants of participation in cervical cancer screening similar to some earlier work done in Zimbabwe on general health service uptake . In the While screening for cervical cancer services are fairly increasing in coverage in Zimbabwe, treatment of confirmed cases has remained challenged , 6. We hLast date of screening” and “Name of health facility where last screening was conducted” in order to validate the screening status. For the patient survey, only participants from public health facilities and an NGO facility were recruited as two private health facilities providing cancer treatment declined to approve this study. However; the majority of cervical cancer patients in Zimbabwe are treated in public health facilities and the inherent bias of conducting this study in these facilities was minimal. Small sample sizes can also compromise statistical precision.The strengths of our study lie in several aspects, mainly that a robust cross sectional design was conducted. The design involved stratification of known confounding variables i.e. area of residence and socioeconomic classification in the surveys. The patient survey was based in tertiary health facilities providing treatment and care for cervical cancer in Zimbabwe. The use of multivariate analyses allowed for meaningful associations to be identified given that confounding variables were adjusted for. More importantly, this study used a structured questionnaire that we designed and validated for use in developing country context . In addiOur study revealed few variations in the participation of women in cervical cancer screening explained by religious affiliations and usage of health facilities. While our results suggested that receipt of cervical cancer treatment was only associated with protestant religious affiliation there may be indirect relationship through disease stage at presentation which in turn influences treatment modalities. There is need to strengthen health education in communities including churches to improve understanding of cervical cancer in an endeavour to increase uptake of screening and treatment services. Strengthening of universal coverage of healthcare services in our low-income context is also recommended. The design of targeted interventions to improve participation in preventive measures and usage of treatment services for cervical cancer is implied.


Support and development of the Australian Aboriginal and Torres Strait Islander health researcher workforce is necessary to realise more effective health policies, a more robust wider health workforce, and evidence-led clinical care. This holds true internationally. It is critical to identify what approaches have resulted in increased numbers of Aboriginal and Torres Strait Islander people in health research, stronger local community partnerships with universities and industry, and research excellence and have contributed to evidence-led health workforce development strategies.This paper provides a narrative review that scopes and integrates the literature on the development and strengthening of the Australian Aboriginal and Torres Strait Islander health researcher workforce. The health The search was for peer-reviewed journal articles between 2000 and early 2018 on capacity building of the Aboriginal and Torres Strait Islander health researcher workforce. Databases searched were CINAHL (EBSCO), PubMed, PsychINFO, LIt.search, and Google Scholar, combined with manual searches of select journals and citations in the grey literature. A coding scheme was developed to scan research coverage of various dimensions of health research capacity building.Twenty-four articles were identified. Eight focused on strengthening research capabilities of community members. A recurrent finding was the high research productivity of Aboriginal and Torres Strait Islander health researchers and strong interest in furthering research that makes a substantive contribution to community well-being. Action-based principles were derived from synthesis of the findings. Generally, research capacity building led to numerous gains in workforce development and improving health systems.There is a shortage of literature on health researcher workforce capacity building. National-level research on capacity building strategies is needed to support the continued success and sustainability of the Australian Aboriginal and Torres Strait Islander health researcher workforce. This research needs to build on the strengths of Aboriginal and Torres Strait Islander researchers. It also needs to identify clear and robust pathways to careers and stable employment in the health workforce, and health researcher workforce more specifically. This need is evident in all settler colonial nations , and principles can be applied more broadly to other minoritised populations. Building capacity of the Australian Aboriginal and Torres Strait Islander health researcher workforce creates a well-rounded and stronger working environment in Indigenous health  and disrThe purpose of this paper is to provide a review that integrates literature from 2000 onwards, to inform research and policy directions on research capacity building (RCB) of the Aboriginal and Torres Strait Islander health researcher workforce, and to provide an evidence base that other minoritised populations internationally can draw from. Given that the Aboriginal and Torres Strait Islander population, which comprises 2.8% of the total  and expeA milestone in centring Aboriginal and Torres Strait Islander people in the health workforce were the Indigenous Research Agenda Reforms connected to the Cooperative Research Centre for Aboriginal and Tropical Health, between 1998 and 2002 . These rMore Indigenous control of research processes with commitment to inclusion, reciprocity and research excellence,us and them to collaborative research between Indigenous and non-Indigenous researchers and organisations,Shifts from From a deficit-focused to strength-based gearing of education and research, and overturning inequities in education ,Marked increases in Aboriginal and Torres Strait Islander people engaged in research, as indicated by the over twofold rise in doctoral students in the last 10 years,Increasing prominence of Aboriginal and Torres Strait Islander academics at high-level governance of universities,Prioritising of projects led or co-steered by Indigenous communities,Research going beyond observation-based studies of illness rates to cultural determinants of health,More recognition of how Aboriginal and Torres Strait Islander people have significantly advanced health research for the benefit of both Indigenous and non-Indigenous peoples,Ongoing significant under-representation in the health workforce (i.e. medicine), with targeted and successful strategies for improvement.Australian Aboriginal and Torres Strait Islander people have until recently been excluded from participation in the health knowledge economy . The heaInternational literature  highlights several central pillars which support health research workforce development –25: RCB A workshop run by the Lowitja Institute identified the need for a nationwide scoping review of progress in RCB , p. 5. TSources were included in the review if they (1) were peer-reviewed journal articles, (2) had capacity building of the Australian Aboriginal and Torres Strait Islander health researcher workforce as a major focus, (3) were published between January 2000 and March 2018 and (4) were in English. The year 2000 marks the midway point of the Indigenous Research Reform Agenda to reconfigure and transform research, especially through centering of Aboriginal and Torres Strait Islander people in research . To reitSearches were conducted from January to March of 2018. The searched databases were PubMed, PsychINFO, CINAHL (EBSCO), Lit.Search and Google Scholar. Titles, abstracts and key words (or subjects) were searched for the following terms in combination: “research capacity building” OR “research training” OR “research workforce” AND Aboriginal OR “Torres Strait Islander” OR Indigenous. Outlets exclusively by and/or on Indigenous peoples were manually searched: Aboriginal and Torres Strait Islander peoples  and the International Journal of Indigenous Health. Via Google Scholar, we checked citations of articles directly about RCB. We also conducted a manual search of the citation lists of each new article that met the inclusion criteria, and undertook a search of reference lists in the grey literature. In addition, we scanned the websites of researchers in Australia that were known by the team to concentrate on Indigenous health, and those individual stakeholders identified through attendance lists to health RCB workshops, roundtables and other events reported in publicly available materials.We mapped the literature on generic fields such as author(s), region, research purpose, general study design, methods and findings. Various forms of RCB (e.g. mentoring) were also recorded. These codes provided the basis for comparing aspects of each paper. In order to identify research model features that may be connected with positive RCB outcomes, the most in-depth publications on discrete RCB programmes were analysed in detail, supplemented by a search for principles of capacity building in the remaining literature. The analysis of RCB programmes included attention to what publication authors highlighted as critical elements to success, as well as discerning consistencies across publications in features that corresponded with good outcomes (e.g. gaining employment after the research training). A working list of research model characteristics was derived out of the analyses.Twenty-four publications were identified , 27–49. Table Enhanced service evaluation skills of health care staff and broader programme assessment capacity of health organisations , 33,After research training and experiences, envisioning a career in the health care workforce  and highNew arrangements for health care providers to openly discuss and reshape the purposes and uses of research data , 46,As an outcome of research that took place during a placement: changes to legislation, paving the way for health data linkage .Several RCB initiatives were taking place within Councils , 33 and Overall, Aboriginal and Torres Strait Islander peoples conducting research do vital work in improving infrastructure of the broader health workforce, such as in the frontline service delivery environment.Research in Australia is primarily funded by the Australian Research Council (ARC) and the National Medical Health and Research Council (NHMRC), two Australian government entities. Aboriginal and Torres Strait Islander people are increasingly influencing the strategic funding of research and the setting of minimal funding targets for Indigenous health-related research . In addin = 14). Suggested reasons for more support of Aboriginal and Torres Strait Islander researchers by Capacity Building Grants included longer funding durations, and utilisation of a “multidisciplinary team mentoring model”  systems, Indigenous Ownership, Leadership and Respect, Identity, and working at the Cultural Interface.” . Challenges were “cultural sensitivities, conflicting priorities and competing agendas …the varying skills, experiences and professional backgrounds of the Indigenous participants” (p. 8). From before BIRC to after, Indigenous researcher outputs went from 36 publications to 131, including an over fivefold increase in conference presentations and almost threefold increase in reports. BIRC members voiced concerns about sustainability, such as a lot of work-in-progress writing for submission to peer-reviewed journals at the end of the programme. The authors pointed out the need for more investment in place (e.g. prolonged funding) to ensure opportunities to further disseminate research and, as part of this, capitalise on the new capacities built during the programme.Elston et al.  reflecteThe Master of Applied Epidemiology (MAE) Program started in 1991, within Australia National University’s (ANUs) National Centre for Epidemiology and Population Health. It was a 2-year coursework degree, consisting of a 3-month intensive coursework and an intensive field placement in applied epidemiology for the remainder of the degree (21-month duration). The field placement would be either Australian based or international. The MAE has played a role in the strengthening of public health workforces and performance internationally. This is especially the case in relation to the establishment and improvement of communicable disease surveillance and response systems .Guthrie et al.  reportedIn a case study report by Hickey et al. , two AboThere were 12 reports on Aboriginal and Torres Strait Islander emerging and senior researcher viewpoints and experiences , 48, 54.Table This review identifies a steadily building body of literature related to RCB of the Aboriginal and Torres Strait Islander health researcher workforce . It indiThe literature reviewed raises several ways that capacity building of the research workforce facilitates capacities of the wider health workforce to better serve Aboriginal and Torres Strait Islander people. There were examples of newly research-trained community members deciding to enrol in university degrees to become health professionals . As descThis paper supplements a review of literature on Aboriginal and Torres Strait Islander research students across all areas of university-based postgraduate education , by focuThrough the current integration of literature, it became clear that there are numerous gaps in knowledge that need to be filled in order to be better placed to inform decisions in workforce development. In order to guide the role of research in workforce planning, Table To bolster the RCB evidence base on best practice at a national level, of significant value would be primary research on the experiences and views of trainees  and theIn turning to the global level, the research model characteristics that we have identified as associated with the most effective capacity building Table  should bThis review provides an incomplete picture of the frequency and diversity of RCB. While the so-called grey literature was beyond the scope, the current searches unearthed sources documenting RCB initiatives, and trainee reflections, e.g. . A revieThe continued growth and development of Aboriginal and Torres Strait Islander health researchers leading health research is a critical element of shaping the health research agenda, and in turn, the well-being of Aboriginal and Torres Strait Islander people. Robustness of the Indigenous health workforce is well served by facilitated growth in the number of Indigenous health researchers. This review identified a paucity of evidence-based literature on RCB throughout the areas pertinent to research workforce development. We call for a redoubling of efforts to upscale and accelerate programmatic research on RCB strategies centred on the strengths of Aboriginal and Torres Strait Islander people, and that prioritise dialogue between local communities, health care and research organisations, and all tiers of government, with due attention to systemic and structural issues. Such research directions may also be applicable to other minoritised peoples in Australia and globally.


Background: This study aimed to systematically review observational studies on perinatal mortality in South Asia. Methods: This review was conducted according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines. Five computerized bibliographic databases: MEDLINE, CINAHL, Embase, PsycINFO, and Scopus were searched for published studies which reported factors associated with perinatal mortality in South Asia from 1 January 2000 to 20 March 2018. All relevant observational studies  were reviewed. Results: Fourteen studies met the selection criteria. The most common factors associated with perinatal mortality were: low socioeconomic status, lack of quality health-care services, pregnancy/obstetric complications and lack of antenatal care. Conclusions: Interventions to reduce perinatal mortality in the South Asia should focus on the provision of adequate antenatal care and quality healthcare services which are accessible to women of low socioeconomic status. Perinatal mortality is a major public health challenge in many low- and middle-income countries (LMICs). Perinatal mortality refers to fetal death after 28 weeks of gestation and before the 7th day of life . In LMICGlobally, the number of perinatal deaths decreased from 5.7 million in 2000 to 4.1 million in 2015 . HoweverPrevious studies conducted in South Asia identified distal determinants such as maternal age , poor soPresently, no study has collectively and systematically analyzed the predisposing factors at the individual-, community-, household-, environmental-, and socioeconomic levels associated with perinatal mortality in South Asia to drive context-specific interventions which will lead to a decline in preventable perinatal death within the region. Hence, the aim of this study was to systematically review the factors associated with perinatal mortality in South Asia, thus contributing to the body of evidence needed to inform effective policy strategies to reduce perinatal mortality, and setting the region on the path to achieving the SDG target by reducing perinatal mortality to as low as 12 deaths per 1000 births by 2030 ,15.The outcome measure for this study was perinatal mortality which refers to the number of stillbirths and deaths in the first week of life .This systematic review was conducted according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines . RelevanRetrieved articles from each database were imported into an EndNote library. To capture relevant publications that might have been omitted, a further search of the bibliographical references of all retrieved articles that met the inclusion criteria was performed, complemented by citation tracking using Google Scholar.[“perinatal mortality*” or “Perinatal death*”]AND[risk* or “risk factor*” or predictor* or determinant* or socioeconomic* or sociodemographic* or factor*]AND[“South Asia*” or “Southern Asia*” or Afghan* or Bangladesh* or Bhutan* or India* or Maldives or Nepal* or Pakistan* or Sri Lanka*]The search strategy was developed using Boolean operators for three major concepts: perinatal mortality, risk factors, and countries in South Asia. The following combination of keywords was used for the search:Eligibility assessment was conducted and studies were included in this review if they (i) focused on perinatal mortality; (ii) were conducted in South Asia; (iii) reported factors associated with perinatal mortality; (iv) were published between 1 January 2000 and 20 March 2018; (v) were observational studies ; (vi) were published in a peer-reviewed journal ; (v) written in English. The inclusion of eight South Asian countries  in our study is based on UNICEF regional classification .All articles identified from the search of each database were imported into an EndNote library and duplicates were eliminated. The first author (PRG) independently read and screened the titles and abstracts of all retrieved articles. In the final screening phase, full-texts of selected articles were identified by PRG using electronic databases, school library and contacting author via email, and studies which met the eligibility criteria were retained after reading the full text. All data extraction and appraisals of retrieved studies were independently reviewed by PRG, BJA and NW, and all disagreements among the three reviewers were resolved through discussion. The summary of the selected studies was recorded, and this included: author, year of publication, country of publication, study design, pregnancy outcome(N), factors associated with perinatal mortality, study limitations, and quality assessment score .The quality of all selected studies was assessed using the National Institute of Health (NIH) Study Quality Assessment Tools for observational studies . The tooA total of 2921 articles were retrieved from the five databases. After applying the selection criteria at each screening stage, a total of 14 articles were retained .Four studies were conducted in Pakistan, 4 studies in Bangladesh, 4 studies in India, 1 study in Afghanistan and 1 study in India and Pakistan . There wLow socioeconomic status was found to be associated with perinatal mortality as reported in studies conducted in India ,18 and BIn this review, suboptimal maternal anthropometry such as low maternal body weight and height  as well Home birth ,30,32, pLow birth weight , small gThis review appraises the methodological quality of reviewed observational studies. We used observational studies because randomized controlled trials are not feasible and only data from observational studies are available for review . FindingSocioeconomic status (SES) was reported to be associated with perinatal mortality in South Asia. Women with low SES have poorer nutrition and less access to quality maternal and child health care services which adversely impacts fetal and newborn health. Previous studies conducted in low ,41 and hIn South Asia, countries such as India, Pakistan and Bangladesh have a health care system which is primarily financed by out-of-pocket money . This maIn a case-control study conducted in Kuwait, it was inferred that access to free maternal health care services for women of lower SES had a significant positive impact in reducing perinatal mortality . FurtherIn this study, lack of maternal health care services such as antenatal care and home birth were reported to be associated with perinatal mortality. The presence and accessibility of quality health care service greatly influence maternal and child health outcomes. A large number of avoidable perinatal deaths are due to inadequate health care services rendered from poorly equipped health care centers with inadequate diagnostic tools and suboptimal maternal care services. Perinatal care is intimately linked to maternal and newborn survival, and thus effective care throughout the continuum of pregnancy, labor, and into the postpartum period is essential . A meta-In this study, maternal obstetric complications such as gestational diabetes, anemia, hypertensive disorders, preterm labor, and intrauterine growth restriction were found to be associated with perinatal mortality in South Asia. These conditions can be identified in the antenatal period, thus reinforcing the need to improve the continuum of care between antenatal identification and subsequent management of complications in health facilities ,52. HencIn South Asia, countries such as Bangladesh, India, Nepal and Pakistan have existing public health policies which include conditional cash transfer and voucher schemes aimed at promoting antenatal, delivery and postnatal care for women of lower socioeconomic status . HoweverThis review is a comprehensive search of the existing literature to report factors associated with perinatal mortality across South Asia. However, this study also had some limitations. First, qualitative studies were excluded from this review. The inclusion of qualitative studies in systematic reviews provides alternative explanations and enables triangulation of findings ,57. SecoFindings from this study are useful for identifying the underlying factors associated with perinatal mortality in South Asia in order to assist in the proper allocation of health resources. These findings will also assist policy makers in planning, developing and implementing of public health interventions which provide appropriate antenatal and obstetric care services aimed at improving maternal health and reducing perinatal mortality at both the individual and community levels. This study also serves as a needs assessment indicator to countries having no representation of research on perinatal mortality to further explore the factors associated with perinatal mortality within its populace.This systematic review found that pregnancy complications are the major causes of perinatal mortality in South Asia. A protective effect of perinatal mortality was found in women who used antenatal care and institutional delivery as well as those with a high SES. Socioeconomic disparity remains a significant barrier to the utilization of maternal and child health services. Hence, cost-effective health care interventions such as quality antenatal care and institutional delivery are needed and should target women of low socio-economic status. Furthermore, due to there being no evidence from some countries in South Asia, there is need to improve data collection by introducing effective health information management systems (HIMS) aimed at assisting health agencies gather data on perinatal mortality to influence current and future needs for health care services.


Background: Blood flow restriction or KAATSU exercise training is associated with greater muscle mass and strength increases than non-blood flow restriction equivalent exercise. Blood flow restriction exercise has been proposed as a possible alternative to more physically demanding exercise prescriptions (such as high-load/high-intensity resistance training) in a range of clinical and chronic disease populations. While the maintenance of muscle mass and size with reduced musculoskeletal tissue loading appeals in many of these physically impaired populations, there remains a disconnect between some of the desired clinical measures for chronic disease populations and those commonly measured in the literature examining blood flow restriction exercise. While strength does play a vital role in physical function, task-specific objective measures of physical function indicative of activities of daily living are often more clinically relevant and applicable for evaluating the success of medical and surgical interventions or monitoring age- and disease-related physical decline.Objective: To determine whether exercise interventions utilizing blood flow restriction are able to improve objective measures of physical function indicative of activities of daily living.Methods: A systematic search of Medline, Embase, CINAHL, SPORTDiscus, and Springer identified 13 randomized control trials utilizing an exercise intervention combined with blood flow restriction, while measuring at least one objective measure of physical function. Participants were ≥18 years of age. Systematic review of the literature and quality assessment of the included studies used the Cochrane Collaboration's tool for assessing risk bias.Results: Data from 13 studies with a total of 332 participants showed blood flow restriction exercise, regardless of modality, most notably increased performance on the 30 s sit-to-stand and timed up and go tests, and generally improved physical function on other tests including walking tests, variations of sit-to-stand tests, and balance, jumping, and stepping tests.Conclusions: From the evidence available, blood flow restriction exercise of multiple modalities improved objective measures of physical function indicative of activities of daily living. Strength or resistance training is a primary exercise modality in exercise prescription guidelines for healthy adults  for improving strength among individuals able to perform HLRT  guidelines.The electronic database search included Medline, Embase, CINAHL, Springer, and SPORTDiscus. Search strategy utilized the search strings identified in the Database search results were imported into Endnote X8 . Duplicates were removed, and screening was completed by title, abstract, and full text. Excluded articles were sorted into individual folders indicating the reason for exclusion until only articles for inclusion remained. This process was completed by two researchers independently. The relevant inclusion criteria are identified below and reasons for exclusions noted in the PRISMA flow chart :Language: only studies published in English were included in this review.Study Design: only studies that employed a randomized control trial (RCT) design were included. Systematic reviews, narrative reviews, conference abstracts, editorials, letters or publications not-inclusive of original data were excluded.Intervention: studies must have included an exercise training intervention in the form of chronic aerobic, resistance, combined, or alternative types of progressive exercise training or significant chronic muscular activation in the primary intervention group or groups over multiple weeks. The primary intervention group must have used BFR during the prescribed exercise training.Controls: control groups in these studies must have been non-BFR equivalent exercise, non-exercising controls, or alternative traditional exercise prescriptions. Within participant controls (single limb interventions) were excluded from the review.Outcomes: must have included at least one objective measure of physical function indicative of ADL. Subjective measures associated with physical function (questionnaires or surveys) were excluded.Examples of objective measures of physical function indicative of ADL include the 6-min walk test (6MWT), variations of the sit-to-stand test, balance tests, or grip strength tests, which have similarities in their execution to everyday activities. Measures excluded from this review include laboratory tests such as maximal strength testing, or graded exercise testing utilizing measures of oxygen utilization, ventilatory or lactate threshold, as these are not reflective of ADL.The risk of bias of included studies was independently evaluated by two reviewers  using the Cochrane Collaboration's tool for assessing risk bias , Embase , CINAHL (795), Springer (691), and SPORT Discus (656). Duplicates were removed to refine the total number of articles for screening down to 3,783. Of these 3,783 articles screened for eligibility, 3,450 were excluded based on title or abstract. The full texts of the remaining 333 articles were evaluated based on the inclusion criteria for this review. Of these, 169 were excluded by study design for not being a RCT or not being a training study, 151 were excluded for not measuring an objective measure of physical function indicative of ADL, and 1 full text was unable to be obtained. Ultimately, 12 studies fulfilled the criteria and were included in the current review. An additional article was identified from the reference lists of prior reviews in the field identified as part of the search and was added to the analyses for a total of 13 included studies.n = 17  and the comparison groups (mean n = 12). The populations examined among studies exploring physical function after BFR exercise training were variable. However, the most commonly examined population was older adults (aged 60 years or over) which was examined in six of the included studies  and clinically significant decrease in time to complete the TUG was observed in five of these studies and was also a significantly greater decrease in time to complete the TUG (10–15%) than their respective comparison groups (3–6%)  , was assessed by six of the included studies  was assessed in a further two of the included studies , while there was no improvement from baseline following a HLRT intervention     is difficult for the outcomes in this review, as this is something that can be markedly variable depending on the population in question, and to try to imply a blanket MCID across multiple populations may be misleading. This would be a valuable addition to the reporting of the outcomes for objectively measured physical function, and future research should provide an indication of what is considered a MCID for the populations they assess. Likewise, large variability in the exercise prescriptions  used among the included studies makes it difficult to elucidate whether any single prescription is particularly useful or more efficacious than another. However, it is difficult to recommend specific exercise prescriptions as this is variable in response to the population group being examined, and the training objectives of note. Perhaps a more apt recommendation is for more repetition of similar exercise prescriptions for specific training objectives among single populations as a means of enhancing evidence that is touched on by previous findings. Finally, while the 30STS and TUG were more frequently examined, making it easier to draw conclusions about the general effects of BFR exercise and performance on these measures, no other single measure of physical function identified in this review was assessed in more than two studies. Thus, more studies examining similar key measures of physical function are required when assessing outcomes from BFR training.Physical function is generally an undervalued and infrequently measured outcome among blood flow restriction exercise studies, which traditionally focus on muscle mass and strength outcomes. Task-specific measures of physical function indicative of activities of daily living may be more clinically relevant and applicable for evaluating the management or progression among chronic disease and other clinical populations (Groll et al., MC was primarily responsible for the conception of and rationale for the review. MC, AM, and SW contributed to the search strategy, the selection criteria, the review, and writing of the manuscript. MC and AM completed the database searches, study selection, and assessment of bias. MC completed data extraction and compilation of results.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.


In 3 regions of Myanmar, village malaria workers (VMWs) and mobile teams tested a higher number of people than strategically placed fixed screening points at border crossings, but VMWs and screening points yielded higher malaria positive rates. We recommend using a combination of these approaches in the Greater Mekong Subregion for such populations depending on the strategic approach of the program. In 3 regions of Myanmar, village malaria workers (VMWs) and mobile teams tested a higher number of people than strategically placed fixed screening points at border crossings, but VMWs and screening points yielded higher malaria positive rates. We recommend using a combination of these approaches in the Greater Mekong Subregion for such populations depending on the strategic approach of the program. Mobile populations and migrant workers are a key population to containing the spread of artemisinin-resistant malaria found in the border areas between Cambodia, Myanmar, and Thailand. Migrants often have limited knowledge of public health, including malaria, services in the area, and many seek care from unregulated, private vendors.Between October 2012 and August 2016, we implemented malaria case finding and treatment in Tanintharyi Region, Kayin State, and Rakhine State of Myanmar through 3 entry points: village malaria workers (VMWs), mobile malaria clinics, and screening points. A total of 1,000 VMWs provided passive case detection and treatment services to residents in malaria-endemic villages. Active case finding through mobile malaria clinics was conducted by staff in 354 remote villages and work sites, where regular monitoring and supervision of VMWs would be difficult to maintain. Malaria screening points were a hybrid combination of active and passive case finding in which screening points were set up at fixed locations in Tanintharyi Region and Kayin State, such as bus stops, ferry docks, or informal border crossing points, and migrants entering into or departing from endemic areas could voluntarily receive malaria testing and treatment. Using routine monitoring data, we assessed and compared the malaria positive rate—the number of positive malaria cases out of those tested—across the 3 approaches as an indication of the programmatic effectiveness in identifying malaria cases in the population. Most testing was conducted with rapid diagnostic tests.Mobile teams  and VMWs  tested a higher number of community members than screening points  as they covered a wider geographical area. However, the malaria positive rate was higher among VMWs (7.29%) and screening points (7.10%) than mobile teams (2.64%). VMWs were located in hard-to-access areas that have higher malaria prevalence and are difficult to reach by vehicle while screening points specifically targeted mobile populations and migrant workers. Mobile teams also screened non-fever patients during their visits, which may explain their lower malaria positive rate.A combination of malaria testing approaches helps achieve both maximum reach and high case finding as it allows access to a range of migrant communities and provides an opportunity for continuity of service delivery as the migrants travel to their destinations. Mobile populations and migrant workers who move from their permanent residence to malaria-endemic areas for work or other purposes are a key population to containing the spread of artemisinin-resistant malaria found in the border areas between Cambodia, Myanmar, and Thailand.There is also significant internal migration in the countries. For instance, it is known that most migrants in Cambodia are internal,There are, however, differences between migrant communities. A study by Wangroongsarb et al. found significant differences between long-term (over 6 months) and short-term Burmese and Cambodian migrants living in Thailand's border areas. Most long-term migrants had heard of malaria, but only about half of short-term migrants had. Short-term migrants were also more likely than long-term migrants not to know any malaria symptoms or preventive methods. Yet a majority  had slept under a bed net the previous night, in accordance with the cultural norms in the Greater Mekong Subregion.P. falciparum malaria in the Greater Mekong, home to large numbers of mobile populations and migrant workers  and the United States Agency for International Development (USAID) Control and Prevention of Malaria  Project, implemented between October 2012 and August 2016, worked in border areas between Cambodia, Myanmar, and Thailand to contain the spread of multidrug resistant  workers . CAP-MalThe CAP-Malaria Project worked in border areas in the Greater Mekong, home to large numbers of mobile populations and migrant workers, to contain the spread of multidrug resistant malaria.National Strategic Plan: Intensifying Malaria Control and Accelerating Progress Towards Malaria Elimination 2016–2020 mentions 2 types of populations: static and migrant.Myanmar's CAP-Malaria's main approach was the establishment of VMW networks to fill service gaps in target areas. Mobile malaria clinics were also organized at least 3 times each year  in very remote areas with a high malaria burden and/or in areas not covered by VMWs or private providers to conduct active case detection and management. Finally, the project established screening points at common entry points for migrants and mobile populations.Because malaria prevalence is often highest in the most remote locations, and as interpersonal communication was found to be the preferred source of malaria information in a CAP-Malaria survey, CAP-Malaria supported at least 1 VMW in each of the target villages that were geographically hard-to-reach and had high malaria case load/transmission, no appointed public health staff, and no other malaria service providers. The VMWs were recruited from their own communities with the help of village chiefs. From October 2012 to March 2015, 1,000 VMWs in total provided malaria prevention and control services in 23 townships in Tanintharyi Region and Kayin and Rakhine States.Between 2012 and 2015, 1,000 village malaria workers provided malaria prevention and control services in 23 townships in Myanmar.VMWs have a strong network with long-term and temporary community residents, and are familiar with local health services. They were trained to provide their respective communities malaria education; help migrants recognize malaria symptoms; diagnose malaria with rapid diagnostic tests; treat simple malaria according to national malaria treatment guidelines and monitor treatment adherence; and refer severe cases  and pregnant women to health centers. Support and supervision was provided during visits by mobile malaria clinics or at monthly township-level meetings to monitor existing or potential diagnostic and treatment stock-outs for provision of continuous malaria services. During the monthly meetings, basic health staff replenished VMW supplies, collected reports, discussed challenges and solutions, and provided refresher training.For migrant communities in remote villages or work sites that could be accessed by motorbike or vehicle, CAP-Malaria introduced mobile malaria clinics to provide screening and treatment of malaria cases. Criteria for communities to be eligible for mobile malaria clinics included: no health facility or volunteer services, recruitment of VMWs impractical due to high costs and inability for them to attend monthly meetings and regularly submit reports because of access issues, or a high malaria burden. Mobile malaria clinics were staffed by a doctor, a microscopist, a health worker, and, when needed, an interpreter. Each mobile clinic served approximately 30 zones or villages in its assigned area. The timing of the mobile clinic's visit was coordinated with the VMW or other local contact who promoted the visit in the community, and village chiefs provided community mobilization. The mobile clinics provided support to the VMWs, replenishing supplies and answering questions.From October 2012 to March 2015, mobile clinics visited 354 villages/work sites in 23 townships in Tanintharyi Region and Kayin and Rakhine States. At the village level, the mobile clinics raised communities' awareness about malaria prevention and the importance of early diagnosis and prompt and adequate treatment. They also offered testing services to anyone in the target community.Mobile clinics visited 354 villages and work sites in remote areas.The project set up malaria screening points at key fixed locations aimed to reach migrants while traveling between sites or during entry into or departure from endemic areas, such as bus stations or jetty terminals. For example, each month thousands pass through the Myoma Jetty and Bus Terminal in Kawthoung Township, a major departure area for Burmese migrants. Screening points were decided in discussion with Township Medical Officers. Migrants could voluntarily have their temperature checked, be tested for malaria with a rapid diagnostic test, and receive treatment if necessary. Migrants were also provided with information on malaria risks, services available, and prevention methods. Screening points were established at bus and boat terminals in Bokpyin and Kawthoung townships in Tanintharyi Region and Hpa-an, Hlaingbwe, Kawkareik, and Myawaddy townships in Kayin State. All testing activities were on a volunteer basis and provided free of charge.The malaria positive rate, or the number of positive cases out of those tested, provides a good indication of the programmatic effectiveness in identifying malaria cases in a population. The number of cases tested and diagnosed through each of the 3 approaches mentioned above  was monitored between October 2012 and March 2015 in Tanintharyi Region and Kayin and Rakhine States. Data were collected from the CAP-Malaria summary database after validation against source documents  by CAP-Malaria staff. Most testing was done by a rapid diagnostic test, with microscopy used only in health facilities implementing a strong quality assurance/quality control system. Privacy and confidentiality of personal information were maintained throughout data collection and analysis.Between October 2012 and March 2015, CAP-Malaria tested more than 330,000 people and provided appropriate treatment to more than 16,000 people who had been diagnosed with malaria .Mobile teams were able to test a higher number of community members as they covered a wider geographical area providing active case detection. The mobile teams also screened non-fever patients during their visits. This may explain the relatively low malaria positive rate of 2.64%.VMWs were an ongoing presence in the hard-to-access areas that have higher malaria prevalence and are difficult to reach by vehicle. VMWs provided passive case detection to patients presenting with fever or symptoms. They tested nearly as many people as mobile malaria clinics  but had a higher malaria positive rate, at 7.29%.Village malaria workers tested nearly as many people as mobile clinics but had a higher malaria positive rate.Screening points specifically targeted mobile populations and migrant workers. Although malaria screening points screened the fewest number of people , they yielded a similar malaria positive rate (7.10%) as VMWs, as these approaches screened suspected patients who presented with fever or symptoms.Effective malaria control among migrant workers and mobile populations requires a combination of approaches for 2 reasons: (1) there are differences between migrant groups in terms of knowledge, health-seeking behavior, and access to services, and (2) the combination of approaches maximizes the opportunities for migrants to obtain information and services while they travel and at their destination community. The 3 service delivery approaches used by the CAP-Malaria project have their advantages and disadvantages in terms of operation and cost.The use of mobile teams can be expensive depending on frequency, distance, and remoteness of the areas covered. However, the more aggressive nature of case finding allows the program to access more people and identify cases that may normally be missed through routine passive case detection. Mobile teams should be provided as a complementary approach to health facility-based and community-based malaria testing and treatment services. Updated malaria information in the local context should be used to plan and implement mobile team activities to ensure higher malaria positive rate and for cost-control measures.The use of VMWs requires a strong monitoring and supervision component to ensure quality of uninterrupted services by VMWs in the community. Operational costs are lower when the monitoring and supervision is integrated into local health systems and rural health staff are engaged as part of monitoring and supervision of VMWs. While this approach is effective in treating uncomplicated malaria, strong linkages and referral systems must be set up to refer complicated malaria cases. Village-based stratification of malaria information is important to effectively allocate resources.Screening points, strategically located in areas highly frequented by migrant communities, combine active and passive case detection. The location and timing of screening points, and the criteria for screening, are important factors in the resulting malaria positive rate. Updated information and continuous evaluation of the results will help to better target resources to improve the malaria positive rate using this approach.The most efficient approach for case finding appears to be through VMWs since they provide quality services with minimal resources required. However, VMWs have only limited reach in a population as they provide services only within their community. In comparison, mobile clinics identify fewer cases but are able to reach more people with malaria services and malaria information with wider geographical coverage. Scheduled mobile clinics contribute to sustain VMWs' activities in remote villages and work sites by replenishing supplies and providing supervision. While screening points resulted in a fewer number of people being tested, they nevertheless identified a large number of malaria cases by specifically targeting mobile populations and migrant workers when routine monitoring was not efficient. Screening points also raise awareness of malaria among travelers, preparing them to recognize malaria symptoms and seek care more quickly in their destination community.Screening points identified a large number of cases by specifically targeting mobile populations and migrant workers.As Myanmar and other countries move toward pre-elimination/elimination, malaria will begin to cluster among certain high-risk groups, including migrants and mobile populations. A combination of program approaches helps increase testing among high-risk populations and achieve high case finding rates, which will be critical to achieve elimination.