In recognition of the failures of sectoral approaches to overcome global challenges of biodiversity loss, climate change, food insecurity and poverty, scientific discourse on biodiversity conservation and sustainable development is shifting towards integrated landscape governance arrangements. Current landscape initiatives however very much depend on external actors and funding, raising the question of whether, and how, and under what conditions, locally embedded resource management schemes can serve as entry points for the implementation of integrated landscape approaches. This paper assesses the entry point potential for three established natural resource management schemes in West Africa that target landscape degradation with involvement of local communities: the Chantier d’Aménagement Forestier scheme encompassing forest management sites across Burkina Faso and the Modified Taungya System and community wildlife resource management initiatives in Ghana. Based on a review of the current literature, we analyze the extent to which design principles that define a landscape approach apply to these schemes. We found that the CREMA meets most of the desired criteria, but that its scale may be too limited to guarantee effective landscape governance, hence requiring upscaling. Conversely, the other two initiatives are strongly lacking in their design principles on fundamental components regarding integrated approaches, continual learning, and capacity building. Monitoring and evaluation bodies and participatory learning and negotiation platforms could enhance the schemes’ alignment with integrated landscape approaches. In sub-Saharan Africa, close to 600 million people are dependent on forests for food and/or income, and many of those are food insecure  and parkia (Parkia biglobosa)  Boffa . These ma) Boffa . Trees aa) Boffa . The fora) Boffa ; uncontra) Boffa .Ghana’s forest cover of 41% (9.3 million hectares) encompasses primary forest (4.2%), naturally regenerated forest (92.3%) and planted forests (3.5%) FAO , p. 229.To address the degradation of forested landscapes, Ghana and Burkina Faso have experimented with several co-management and community-based NRM initiatives since the 1930s and 1970s, respectively Agyeman . These iIn Burkina Faso, forest resource management involving rural communities was piloted in 1985 in the Nazinon forest reserve of Sissili Province in the Center-West Region with international donor support and joint implementation by the United Nations Development Program (UNDP) and the Food and Agricultural Organization of the United Nations (project UNDP/FAO/BKF/85/011). Offices of the Ministry of Forest and Environment and Sustainable Development (MEDD) were established in the communities and out-posted technicians to provide training on improved methods of tree felling and regenerative coppicing and informing forest management cooperatives . The Chantier d’Aménagement Forestier (CAF) scheme regulates fuelwood harvesting by issuing permits to the forest management groups. Felling permits detail the quantity and type of wood species to harvest from the forest reserve. The revenues of fuelwood trade are distributed on a ratio of 9.1, 13.6, 27.3, and 50%, respectively for the forest tax (harvesting permit), contribution to the village development fund, the forest management fund, and the forest management group members (Ouédraogo The modified taungya system (MTS) in Ghana is a reforestation scheme launched in 2002 to replace the original taungya introduced in the 1930s in response to rapid forest loss within reserves due to the high demand of forest resources by then colonial authorities  designed to address landscape degradation while recognizing the long-standing natural resource demands and livelihood objectives of inhabitants, and (2) are the principal NRM schemes in the two countries involving local communities and other stakeholders.The literature referred to in this study  was gathered in four steps. First, gathering peer-reviewed sources involved a search through the Web of Science database, using the names of schemes and their acronyms. Second, additional ‘gray literature’ was sought using the same keywords in Google Scholar. Publications that focused on the performance and governance aspects of the schemes were selected for further review. Third, unpublished documents were found through the researchers’ previous project work in both countries. For Burkina Faso, relevant policy documents and published and unpublished literature was acquired during scoping visits to identify project sites and research partners for the “Sustainable Use of Tropical Forest Biodiversity” project. Similar data on the schemes in Ghana was gathered through long-established contacts with the Wildlife Division and Research Management Support Center—two divisions of the Ghana Forestry Commission responsible for the respective schemes. Fourth, bibliographies of source documents were assessed to identify additional articles, reports, and outputs. Key literature on integrated landscape approaches was known to the authors based on a prior review  and cooperative unions (UGGFs) and both meet with the Audit Committee annually. Technicians frequently meet with village-level GGFs as part of a biodiversity monitoring routine. Provincial and regional MEDD offices also meet annually to evaluate performance of conservation priorities and to renew objectives. UGGFs are invited to attend, but they usually delegate attendance to the CAF technical director who has the capacity to engage in such meetings. Whether the technical director attends depends on availability of resources. There are no dedicated platforms where all actors of the scheme can collectively negotiate conservation objectives and challenges. Local CAF organizations often request intermediaries— from either CAF Technical Units, NGOs, or research institutions—to negotiate conservation goals to the regional MEDD on their behalf Westholm . Hence, Per CAF regulations, technicians receive trainings and refresher conservation education annually, but from record, technicians in the CAF may go for 3 years without receiving new training. The CAF is dependent on external NGO projects for capacity building or trainings on new forest management techniques. There is no explicit focus on capacity building within the CAF beyond the formation of cooperatives and cooperative unions. This limits the capacity of woodcutters and their representatives to negotiate trade-offs of competing land use between them.The MTS exhibits characteristics of an integrated approach by combining timber production, intercropping of food crops, carbon sequestration and climate change adaptation   financed a stakeholder consultation in 2001–2002 during which farmers, communities, land owners and NGOs were consulted on the design of the MTS  during the years of AfDB support to the community forest management plan. This type of training focuses on transferring skills rather than enhancing farmers’ negotiation capacity and empowerment  preventing the conversion of wildlife habitat into farmland  and tree crop farming  in Ghana. All three landscapes are impacted by deforestation, biodiversity loss, climate change, and persistent poverty—solutions to which may be sought via integrated approaches. However, the CREMA is the only scheme explicitly embarking on multifunctionality and addressing trade-offs between conservation and development aims. This highlights the potential for the CREMA as a potential entry point for implementing integrated approaches.As far as CAF forests are concerned, there are insufficient linkages between NRM and broader development strategies, despite these forests being historically embedded in multiple land-use mosaics of agroforestry, crop production and agro-pastoralism. Burkina Faso’s current poverty alleviation plans prioritize agricultural expansion and intensification, which can exert further pressure on forests and non-agricultural land  or through the inherent re-design of the scheme to enable farmers to benefit from resource management efforts (the MTS).Improving the interconnectedness of land uses in the CAF requires platforms of collective deliberation on issues of rural development, resource governance and climate change in which different land users are represented. This will reflect the reality of how rural actors utilize and preserve natural resources on the ground.A lack of long-term funding and economic incentives threaten the durability of the MTS, while hierarchical governance arrangements impede a genuine transformation toward collaborative decision-making, power sharing and institutional diversity (Ros-Tonen et al. Concrete monitoring and evaluation mechanisms are key features missing from all three schemes. Monitoring contributes to identifying weaknesses within NRM schemes through evaluation of their biodiversity, economic sustainability, and social relevance (Lovell and Johnston The types of knowledge deemed relevant in NRM schemes can influence the level of involvement of local user groups who often possess locally specific knowledge (Clark et al.


Research using virtual reality assessment of functional capacity has shown promise as a reliable and valid way to assess treatment response in patients with established schizophrenia. There has been little work on virtual reality based assessments of functional capacity for patients in the early phase of schizophrenia. We examined whether virtual reality based assessment methods reveal functional capacity deficits in young patients and relevant relationships with established measures of neurocognition, functional capacity performance, and daily functioning.The sample consisted of UCLA Aftercare Research Program patients (n=42) who were diagnosed by trained raters administering the SCID and who met criteria for schizophrenia, schizoaffective disorder, or schizophreniform disorder, and screened normal control subjects (n=13). Patients were within 2 years of their first psychotic episode upon clinic entry, were an average of 23.2 years old, and had an average of 12.9 years of education. The Virtual Reality Functional Capacity Assessment Tool (VRFCAT) was the computer-based measure of functional capacity. We used the MATRICS Consensus Cognitive Battery (MCCB) as an objective measure of neurocognition and the UCSD Performance-Based Skills Assessment (UPSA) to assess functional capacity performance. The Global Functioning Scale: Role and Social, and the Role Functioning Scale were used to assess work and school performance, familial interactions, and social functioning.We were able to confirm that the deficit in functional capacity performance measured using VRFCAT is present in the early course of schizophrenia in that the patients were slower and committed more errors (M=830.41) as compared with normal controls . Virtual reality based assessment of functional capacity was correlated with objective measures of neurocognition , r=-.71, p=<.01, standard approaches to functional capacity assessment (UPSA), r=-.66, p=<.01, work and school functioning , and level of social relationships , but not familial relationships . Interestingly, neither neurocognition (MCCB) nor functional capacity performance (UPSA) were correlated with the level of familial relationships.We extend previous findings in that even patients in the early course of schizophrenia showed virtual reality based functional capacity performance deficits when compared with normal control subjects. Virtual reality based performance was correlated with neurocognition, suggesting that it may be sensitive to changes in cognition. Furthermore, correlations with everyday work/school and social functioning indicate promise as a co-primary measure to index change in functioning in response to treatment. Interestingly, none of our measures of functional capacity or neurocognition were correlated with familial relationships indicating that the determinates of family interactions might be driven by factors other than cognitive capacities.


With the ongoing demographic and epidemiological transition, cancer is emerging as a major public health concern in India. This paper uses nationally representative household survey to examine the overall prevalence and economic burden of cancer in India. The age-standardized prevalence of cancer is estimated to be 97 per 100,000 persons with greater prevalence in urban areas. The evidence suggests that cancer prevalence is highest among the elderly and also among females in the reproductive age groups. Cancer displays a significant socioeconomic gradient even after adjusting for age-sex specifics and clustering in a multilevel regression framework. We find that out of pocket expenditure on cancer treatment is among the highest for any ailment. The average out of pocket spending on inpatient care in private facilities is about three-times that of public facilities. Furthermore, treatment for about 40 percent of cancer hospitalization cases is financed mainly through borrowings, sale of assets and contributions from friends and relatives. Also, over 60 percent of the households who seek care from the private sector incur out of pocket expenditure in excess of 20 percent of their annual per capita household expenditure. Given the catastrophic implications, this study calls for a disease-based approach towards financing such high-cost ailment. It is suggested that universal cancer care insurance should be envisaged and combined with existing accident and life insurance policies for the poorer sections in India. In concluding, we call for policies to improve cancer survivorship through effective prevention and early detection. In particular, greater public health investments in infrastructure, human resources and quality of care deserve priority attention. Karkinos” (for crab) which refers to a generic non-communicable disease (NCD) characterized by growth of malignant (cancerous or neo-plasms) abnormal cells (tumor/lump) in any part of the human body [The term “Cancer” is derived from the Greek word “man body –2. Althoman body –5. Globaman body –12. In fman body –14. The man body . Howeverman body –17. GiveAgainst this backdrop, this paper examines the distributional patterns in self-reported prevalence and economic burden of cancer in India. According to WHO, India has a cancer mortality rate of 79 per 100,000 deaths and accounts for over 6 percent of total deaths . These nAlthough, there are a few small-areas or hospital-based studies that highlight the concern of high OOP expenditures but certainly these are insufficient to comprehend the situation from a macro-perspective –36. For A disease-centric approach on cancer assumes salience because of specific national policy commitments to ensure universal access to health care at affordable prices . AlthougSocial Consumption: Health survey (71st round) of India. The survey was conducted in 2014 by National Sample Survey Organization (NSSO), Ministry of Statistics and Program Implementation, Government of India. A key objective of Social Consumption: Health survey is to obtain data on aspects of morbidity, treatment-seeking and financing of hospitalization (inpatient) and ambulatory (outpatient) care services for the reference period of 365 days and 15 days respectively. The ailments for which such medical care is sought, the extent of use of Government hospitals, and the expenditure incurred on treatment received from public and private sectors, is also available through this survey. Additionally, the survey provides household level information on demographics and access to services and utilities as well as individual level data on age, sex, education, monthly per capita expenditure and primary occupation of households.This study is based on nationally representative data from Social Consumption: Health Survey interviews are conducted with a representative sample of households randomly selected through a stratified multi-stage survey design covering India. A rural/urban stratification is created within clusters called state-regions, which comprises of a continuous group of districts within a State or union territory having similar characteristics. Within each district of a State/Union Territory, two strata were formed: the rural stratum comprising of all rural areas in the district, and the urban stratum comprising of all urban areas in the district. Selection of first stage units is based on the principle of probability proportional to size with circular systematic sampling of census-identified villages in the rural sector and urban frame survey blocks in the urban sector of each district. Larger sample villages and blocks are divided into a suitable number of "hamlet-groups"/"sub-blocks" of roughly equal population content. Second-stage sampling constituted the households belonging to only two of these hamlet-groups, selected circular systematically in case of sample villages, and one randomly selected sub-block in the case of sample blocks. Households within a village are categorized in two strata based on affluence. From these strata, households are circular systematically selected to constitute the final sample. This cross-sectional survey data was collected during January to June 2014. The 71st round of Morbidity and Healthcare Survey covers a sample of 65,932 households and 335,499 individuals.The First, we present the self-reported prevalence of cancer across socioeconomic groups. For analytical purposes, prevalence of cancer refers to any person suffering from any type of cancer or received cancer inpatient or outpatient treatment (or both). These estimates are presented along with the percentage of cancer patients undergoing treatment in public and private healthcare facilities separately.Further, the estimates for average out of pocket (OOP) medical and total expenditure on cancer inpatient care across SES groups are also reported. The medical expenditure mainly includes information on doctor’s/surgeon’s fee, expenditure on medicines, diagnostic tests, bed charges and other miscellaneous expenses . The total expenditure is the summation of medical expenditure and transport charges for patient, food transport on others, expenditure on escorts and their lodging charges. It is observed that the number of sample cases for cancer outpatient care is almost negligible whereas most of the cancer patients have reported receipt of hospitalization care. Therefore, the expenditure analysis specifically focuses on hospitalization expenditure related to cancer treatment across socioeconomic groups.A high reliance on OOP spending is a major concern and hence it can potentially jeopardize the customary living standards of the households –45. To uWe focused on three SES indicators: household monthly per capita expenditure (MPCE) quintile, education and social group of the cancer patient. Significant milestones of the Indian education system were followed to categorize the patients as illiterate , primary education or below (1–5 years), middle school education or below (6–10 years), secondary education (11–12 years) and higher education (graduate school and above). Social group was categorized as scheduled tribes (ST), scheduled castes (SC), other backward classes (OBC) and other castes. The SC and ST households have historically been economically, socially and geographically deprived groups in India whereas the ‘other castes’ households have, on average, relatively better SES compared to the SC and ST households. In addition, we also include information on household location , sex of the patient, religion  and region of residence.We report levels of cancer prevalence as well as treatment expenditure across socioeconomic categories. The concentration index (CI) is used to discern the socioeconomic gradient in cancer prevalence and its healthcare utilization –48 with The self-reported cancer prevalence at national level and its distribution across socioeconomic groups by rural and urban areas is presented in We use multilevel logistic regression to examine the association between socioeconomic correlates and cancer prevalence . Age of Further, about 61 percent of cancer inpatient cases are utilizing private facilities in urban areas . Female The incidence of distressed financing is significantly high for both public and private hospitals across all wealth quintiles . About 5Finally, it is observed that a significant proportion of cancer patient households spend more than 10, 20 and 40 percent of their annual per capita household expenditure on inpatient treatment . OverallThe present analysis, however, is sensitive to the following limitations. First, the cross-sectional nature of data and survey design does not allow us to infer causality. Second, the results presented here are based on self-reported household survey information. Due to data limitations, we are also not able to assess the respective contributions of different types of sources of financing in total out of pocket expenditure. Similarly, a lack of information on the nature of cancer further prohibits any analysis associated with these dimensions. Finally, because of sample size limitations we could not assess the socioeconomic patterns across all regions and states in India.Increasing prevalence of cancer is a major public health concern. The issue assumes utmost relevance for developing countries such as India because of large population base, limited diagnostic facilities, very high treatment costs and poor survival prospects. Given the nature and consequences of the ailment, it is therefore critical to systematically track the distributional and financial aspects of the disease through rigorous nationwide assessments. In this regard, we find that the overall self-reported prevalence of cancer is estimated to be 83 per 100,000 persons with a greater prevalence in urban areas . The figures correspond with the overall cancer mortality estimates presented by World Health Organization (i.e. 75 per 100000 persons) . In addiThe higher burden of cancer among elderly cohort and in demographically advanced states implies greater requirements of tertiary care facilities in these regions. The cancer incidence among reproductive age cohort is considerably high in females. These estimates call for a greater policy emphasis on higher burden of breast  and uterine cancer among females –58. FurtPrivate sector health care facilities are more accessed for cancer treatment in India. In particular, richer households rely more on private hospitals for cancer inpatient care, whereas poor households mainly depend on public healthcare facilities. Further the average OOP expenditure is much higher for richer households as compared to poor households. Besides, average expenditure in private facilities is almost two times higher than public facilities. We also find that, treatment of cancer causes substantial financial shocks and affect the usual living standard of households. Evidently, one in every three cancer patient’s households spends about half of per capita annual household expenditure on cancer hospitalization. The prevalence of catastrophic expenditure is highly concentrated among poor households implying great importance of wealth and physical capital in ensuring quality tertiary healthcare. A large number of households in low-income countries incur financial debts and sell assets in order to finance their health care payments especially for NCDs like CVD and cancer , 46, 59.Given the magnitude and financial implications, a two-pronged policy approach is essential. First, it is critical to target the risk factors of cancer prevalence across all the sub sections of population and second, to ensure quality and affordable care to all cancer patients. It is widely discussed that India is experiencing accelerated aging; therefore, it is desirable to develop special geriatric oncology facilities as elder cancer patients–in most cases–cannot sail through the general treatment and therapies . FurtherHuman Papilloma virus (HPV) is ranked as most frequent form of cancer among Indian women [High prevalence of cancer among reproductive age cohort, particularly in females, cautions significant policy attention along with specific efforts for pediatric cancer treatment that currently lacks priority in policy discourse . In thisan women . Studiesan women . In lighan women , 8,66–68an women . In addian women –70.A few studies suggest that more than half of the cancer cases can be successfully treated if detected at right stage . TherefoPradhan Mantri Suraksha Bima Yojana (PMSBY), particularly for vulnerable and destitute households.These findings clearly outline the need for greater public health investments in cancer treatment facilities including infrastructure, medical practitioners and accessibility. For instance, with the given population of country, there is requirement of 1200 radiotherapy machines, whereas only 400 machines are available at present for cancer treatment . BesidesFollowing such impoverishing and catastrophic effects, there needs to be more clarity from policies regarding financing mechanisms for such high-cost disease. The relevance of such policy guidelines is all the more necessary because of a prominent role envisaged by the National Health Policy 2017 the private sector in secondary and tertiary health care . Thus, iAt this point, it is important to mention that this study is based on National Sample Survey (NSS) self-reported data on cancer. While this study mainly aims at analyzing out of pocket expenditure and financial hardships on cancer inpatient treatment, information on availability and cost of drugs, access to modern techniques of treatment is also desirable. Further, estimates on catastrophic expenditure at different thresholds  across different population groups does-not reveal the information about willingness of households to spend on cancer care. However, it will be interesting to explore the household level differences in willingness to spend on healthcare in general and chronic diseases in particular.S1 Table(DOCX)Click here for additional data file.S2 Table(DOCX)Click here for additional data file.S3 Table(DOCX)Click here for additional data file.S4 Table(DOCX)Click here for additional data file.S5 Table(DOCX)Click here for additional data file.S6 Table(DOCX)Click here for additional data file.S7 Table(DOCX)Click here for additional data file.


The goal of IPRCE is to reduce the burden of violence and unintentional injuries, which is accomplished through the missions of five distinct task forces comprised of diverse professionals and disciplines representing universities, public agencies, private organizations, and community stakeholders. The five task forces include the following: (A) Fall Prevention, (B) Drug Safety, (C) Traumatic Brain Injury (TBI)/Concussion Prevention, (D) Transportation Safety, and (E) Violence Prevention. Each task force works regularly and closely with a common Associate Director of Programs. IPRCE supports all task force initiatives by assisting with organization, establishing connections, assisting to identify funding sources, and providing expertise with respect to research, training, and education, community outreach, and policy.Nationally, it is well recognized that falls among older adults are a growing public health concern because of their prevalence and ramifications associated with injury, morbidity, loss of independence, premature mortality, and societal costs –7. TheseGiven this “u-shaped” trend for fall-related ER visits in Georgia, the IPRCE Fall Prevention Task Force addresses falls across the lifespan continuum, with special emphases on older adults and infant/toddlers. The goals of the task force are to (A) set the goals and priorities for the task force based on the regional, state, and local data; (B) identify research gaps and guide studies that will address root causes of falls within the community; (C) develop a strategic plan to address research/service gaps, which involve the community as collaborators; (D) assist with the implementation of recommended interventions; (E) set specific deadlines and metrics for documenting success; and (F) provide consultation about the development and evaluation of evidence-based fall prevention programs.Following these task force goals and driven largely by the data presented in Figure The dual population foci of this task force foster innovation to address falls among older adults. For example, intergenerational approaches to address falls are emerging, which primarily target the “sandwich generation”  as changGiven the array of multilevel evidence-based programs and solutions to address older adult falls, the need for this Fall Prevention Task Force to develop new interventions is diminished. Instead, this task force recognizes that multi-level fall prevention efforts often occur in silos , and intTo conclude, the IPRCE’s mission to address injury in Georgia explicitly targets fall prevention for children and older adults as a complement to existing Georgia Fall Prevention Coalition efforts. This task force is emerging as the advisory group for science and innovation for fall prevention in the state. Through this collaborative, efforts to serve older Georgians with fall prevention interventions and resources will be complemented with research and evaluation expertise. This model to complement SFPC has vast implications for replicability in other states and has potential for strategic planning and leveraging efforts to expand funding for fall prevention statewide.MS, SC, SN, RB, KG, and EH were involved in the writing and reviewing of the manuscript.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


In 2013, people over 55 years old accounted for 26% of the estimated number of people living with HIV (~1.2 million). The aging brain is increasingly vulnerable to endogenous and exogenous insult which, coupled with HIV infection and comorbid risk factors, can lead to additive or synergistic effects on cognitive and motor function. This paper reviews the literature on neuropsychological and  The concept and benefits of combining multiple drugs for treatment of Human Immunodeficiency Virus (HIV) infection was introduced in 1996 , 55,000–60,000 new infections are reported, with an estimated total of ~1.2 million infected individuals. In 2013, people ≥50 years old accounted for 17–26%  of the HIV population  or accelerated (synergistic) aging. Infection may facilitate processes compromised by older age resulting in premature aging, during which changes occur earlier but in parallel to normal aging or accelerated aging, wherein changes occur at a faster rate than in normal aging Figure . ResultsIn the following, the literature on brain structure and function in HIV and relevant comorbidities  is reviewed, with a focus on longitudinal studies to help clarify the independent or interactive effects of older age. Table Age-related medical conditions  are not usually observed in the general population until over age 60: in HIV-infected patients, such conditions may present at middle age or sooner  is ideally assessed using comprehensive neuropsychological batteries and interpreted using demographically appropriate normative data  than with HIV-related variables  and severe (CDC stage C) stages of HIV infection relative to changes observed in infection-free controls and faster rates of white matter volume decline in the HIV-infected subgroup with stage C than stage A severity level. Further, decline in caudate nucleus volume and increase in ventricular volume were greater in the HIV-infected group that progressed from a less severe to a more severe CDC stage across MRI sessions, and these changes in brain volumes correlated with decline in CD4 cell count  on fluid attenuated inversion recovery (FLAIR) images from MRI. WMH may reflect vascular or inflammatory brain changes  and associated with hypertension  and implicit  memory , choline-containing compounds (Cho), and total creatine (tCr). NAA is an indicator of neuronal integrity, with decreases suggesting neuronal dysfunction  is associated with low levels of NAA and changes (both increases and decreases) in Glu levels (often quantified from the combined resonance of glutamate + glutamine and referred to as Glx) in regions including frontal cortex and basal ganglia , greater numbers of activated (CD16+) monocytes were associated with lower NAA and higher Cho levels in frontal cortex  and high mean diffusivity (MD)] in markers of myelin  and axonal  integrity, even in normal-appearing white matter, notably in corpus callosum and frontal lobe white matter  revealed in all patient groups relative to controls lower integrity of callosal regions (Pfefferbaum et al., In HCV, FA has been reported as low in fiber tracks including the corpus callosum, middle cerebellar peduncles (Bladowska et al., Getting old with HIV appears to cause premature aging with respect to medical conditions, psychiatric comorbidities, and neurocognitive performance. Structural MRI findings suggest accelerated aging of select brain gray matter volumes, but equivocal evidence for an interactive increase in WMH burden in older HIV-infected individuals. Current DTI studies are similarly conflicting as to whether older age and HIV have interactive effects on white matter integrity. The literature remains sparse with respect to longitudinal studies, which will help distinguish between healthy, premature, and accelerated aging with HIV.ART has largely controlled the HIV epidemic, but fundamental questions regarding the precise cause of neurocognitive dysfunction in HIV remain. In the post-ART era, persistent issues related to an aging HIV population include effects of common comorbid conditions, such as AUD and HCV infection. Neuroimaging points to the sensitivity of the thalamus to HIV infection. High-resolution imaging and segmentation of thalamic substructures may provide a more refined understanding of the substrates underlying cognitive decline in HIV. DTI has been underutilized in studying the HIV brain and thus also holds promise for clarifying the brain regions involved in HIV-associated cognitive and motor impairments and in explicating mechanisms that may contribute to dysfunction with age. Free water imaging, a DTI analysis method that improves the specificity and sensitivity of DTI by accounting for extracellular water (Pasternak et al., NMZ envisioned and wrote this review manuscript and is accountable for all aspects of the work.The author declares that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Outcomes of floret initiation, mortality/survival, grain set/abortion, and fruiting efficiency have been quantified in 30 cultivars and connected to the processes determining the fate of floret primordia using ovary size. Triticum aestivum L.). Here, we examine the genotypic variation in three important traits: maximum number of floret primordia, number of fertile florets, and number of grains. We determine their relationship in determining spike fertility in 30 genotypes grown under two contrasting conditions: field and greenhouse. The maximum number of floret primordia per spikelet (MFS), fertile florets per spikelet (FFS), and number of grains per spikelet (GS) not only exhibited large genotypic variation in both growth conditions and across all spikelet positions studied, but also displayed moderate levels of heritability. FFS was closely associated with floret survival and only weakly related to MFS. We also found that the post-anthesis process of grain set/abortion was important in determining genotypic variation in GS; an increase in GS was mainly associated with improved grain survival. Ovary size at anthesis was associated with both floret survival (pre-anthesis) and grain survival (post-anthesis), and was thus believed to ‘connect’ the two traits. In this work, proximal florets  produced fertile florets and set grains in most cases. The ovary size of more distal florets (F4 and beyond) seemed to act as a decisive factor for grain setting and effectively reflected pre-anthesis floret development. In both growth conditions, GS positively correlated with ovary size of florets in the distal position (F4), suggesting that assimilates allocated to distal florets may play a critical role in regulating grain set.Spike fertility traits are critical attributes for grain yield in wheat ( Triticum aestivum L.) yield remains one of the main objectives of wheat breeding efforts   ; likewisvulgare) . Increasvulgare) a and bavulgare) . Complemvulgare) , irrespevulgare) , but alsvulgare) .Most of the few studies analysing the dynamics of floret development as a determinant of grain number have focused on environmental effects. Very few have included genotypic variation, and, when that variation was considered, the number of genotypes analysed was extremely low. Assuming a parallelism with the relationships uncovered with environmental effects . Growth conditions for both experiments have previously been described (Experiments were carried out at the Leibniz Institute of Plant Genetics and Crop Plant Research (IPK), Gatersleben, Germany  during the 2012/13 growing season in two contrasting environmental conditions: greenhouse and field. Thirty European hexaploid winter wheat cultivars were grown, including 23 photoperiod-sensitive and 7 photoperiod-insensitive cultivars. These genotypes can also be classified into 24 semi-dwarf and 6 tall cultivars. Marker information for all 30 cultivars is presented in To determine the maximum number of floret primordia, plants around the GA stage , central (the spikelet in the centre of the spike), and basal positions (the third spikelet from the bottom) . At AN, −1), and grain survival was determined as the proportion of the fertile floret number that set normal grain (GS FFS−1). Floret abortion was determined as the number of floret primordia that did not reach the stage of fertile florets, and grain abortion was calculated as the number of fertile florets that did not produce a normal grain. ‘Normal grains’ are defined as seeds that are completely developed, are not shrivelled, and have a size that is not particularly reduced.Floret survival was calculated as the proportion of the maximum number of floret primordia that reached the stage of fertile florets . The broad genotypic variation  and relatively high heritability (2E) and influence of the interaction between environment and genotype (σ2G:E) were large for most traits according to an ANOVA analysis . In summary, there was a large degree of variation and also moderate to high heritability among the 30 cultivars analysed for all the traits determined; detailed data for individual genotypes are shown in Supplementary Tables S2, S3, S4, and S5.MFS, FFS, and GS varied widely in both growth conditions and across all spikelet positions studied . Despitetability  indicateanalysis , the regSupplementary Fig. S3), although there were a number of exceptions .Averaging across spikelets, it is quite clear that even though there was substantial phenotypic variation in MFS (average of the three spikelets), the genotypic differences in FFS (average of the three spikelets) were almost exclusively due to genotypic differences in the survival of floret primordia (average of the three spikelets) , b. ThisSupplementary Fig. S4a, b, c) and unrelated to MFS . Again, at each spikelet position, it was evident that differences in MFS significantly induced parallel differences in floret abortion . While the relationship between FFS and floret survival was highly significant for all three spikelet positions in both field and greenhouse conditions , the relationship between FFS and MFS was only significant in three of the six cases analysed. Even in those in which it was significant, R2 was very small (MFS never explained more than 18% of the variation in FFS).We found compelling evidence for the relative importance of floret survival compared with MFS in determining genotypic differences in FFS among modern cultivars after analysing the relationships for each spikelet position independently. At each particular spikelet position, and in both growth conditions, FFS was strongly significantly related to the proportion of primordia surviving , while those between GS and FFS were maintained in the greenhouse experiment but disappeared in apical and central spikelets  in the field experiment . The positive relationship  was also maintained between grain abortion and FFS at the spikelet level position .Analysing the results at the individual spikelet position level showed that the relationships between GS and grain abortion were maintained . The analytical framework included three parameters in the dynamics of generation/degeneration of organs determining spike fertility: MFS, FFS, and GS. The MFS is the consequence of floret primordia initiation starting around TS stage and finishing approximately at GA; the FFS is the outcome of the floret primordia mortality/survival process occurring broadly from GA to AN; and GS is the result of grain set/abortion taking place in the ‘lag phase’ of roughly 7–10 days after AN to the onset of grain growth. Here, we not only quantified the outcomes of floret initiation, floret mortality/survival, and grain set/abortion in 30 modern cultivars , but also tried, for the first time, to connect parts of these processes by describing the association between ovary size of distal florets with the number of fertile florets and grains. Interestingly, MFS, FFS, and GS exhibited not only large variation in both growth conditions and across all spikelet positions studied, but also displayed moderate levels of heritability. It has previously been reported that ovary size has high heritability  . Here weOvary size at AN is the result of floret initiation and degradation, and represents a possible predictor for grain setting . InteresThe observed non-grain setting even in F1 and F2 under ‘ideal conditions’ suggests other limiting factors for grain setting. For example, some stresses around meiosis  can reduce grain set in these favoured positions, giving obvious spike ‘sterility’ despite no obvious growth limitations , number of fertile florets (spikelet−1), number of grains (spikelet−1), and fruiting efficiency between greenhouse and field conditions.Figure S3. Relationship between the maximum number of floret primordia and floret survival within apical, central, and basal spikelets under field and greenhouse conditions.Figure S4. Relationship between the maximum number of floret primordia, fertile floret number, and floret abortion within apical, central, and basal spikelets under field and greenhouse conditions.Figure S5. Relationship between the maximum number of fertile florets, number of grains, and grain abortion in apical, central, and basal spikelets under field and greenhouse conditions.


We highlight the commitment to community partnerships in the aftermath of the 2010 Deep Water Horizon Oil Spill, and how that commitment helped improve science. We provide examples of community-academic partnerships across the engagement spectrum. Finally, we offer suggestions to improve the community engagement in order to cultivate more long partnerships and better scientific research.On the occasion of the 50 The 2010 Deepwater Horizon (DWH) Oil Spill resulted in extraordinary visibility and pressure to address the ecosystem impact of this unprecedented disaster. Despite the largest ever occupational epidemiologic study involving 32,000 workers undertaken by NIEHS internally [The National Institutes of Health (NIH) postwar expansion was based upon recognition of the value of peer-reviewed research predominantly by physician-scientists who effortlessly could move from laboratory to clinic and back again. The NIH grants program grew from $4 million in 1947 to $100 million in 1957 and to $1 billion in 1974 accompanied by major growth in its intramural program . New insInitially, the critical health impact of NIEHS-funded research occurred through translation and application to national policies. Responding to national concerns about air and water pollution, and toxic agents such as lead, poly chlorinated biphenyls and benzene, these research endeavors led to policies that saved many lives. NIEHS research also generated the tools to prevent introduction of new chemicals with undesirable properties such as mutagenesis and neurotoxicity. Unfortunately, with NIH as a whole focusing on the environmental impacts on individual patients, and NIEHS focusing on basic science research leading to changes in public policy, communities received little attention. However, over time there was a growing appreciation for striking differences among communities in environmental hazards, perceived risks, and behavioral reactivity that were central to understanding and ameliorating environmental health impacts. Recognizing the importance of community-based research, the leadership of NIEHS, −with special credit to Directors Ken Olden and Linda Birnbaum-, advocated this as a core area of environmental health science, including mandating that all NIEHS-funded Research Centers have an outreach program focusing on the community. Additional NIEHS-led research advocated for greater emphasis on community based participatory research .The NIEHS commitment to community partnerships is often tested in response to natural and man-made disasters , 4. Concth percentile rate [At the project level, significant advances in environmental health research were facilitated through innovative community collaborative techniques: for example, researchers worked with community partners in planning, and implementing a targeted health risk assessment of seafood most relevant to a local Vietnamese community . Mary Quile rate . Despiteile rate , consortile rate . This meile rate . Specifiile rate .Similar to MQVN, Bayou Interfaith Shared Community Organizing (BISCO), another GROWH community partner, was actively engaged in the placement and collection of paired indoor and outdoor air monitors . The anaBuilding Resilience Through Disaster Mobile Health” is illustrative of the most intensive community engagement at the project level: community members were trained and embedded in the study design through the community health worker (CHW) model [“W) model . Data shW) model , 21.active coping strategies buffer negative mental health outcomes during the oil spill disaster, while the increased use of disengagement coping was associated with higher levels of anxiety and depression both during [p < .001) thereafter. With respect to the burden of intensive media coverage, one year after the DWH oil spill, the total time an individual was re-exposed to the spill and its environmental consequences through television, radio, print media and internet sources was not associated with overall mental health, but was significantly associated with hypervigilance, one symptom of anxiety [Research documented the combined effects of the oil spill with the other disasters (most notably Hurricane Katrina) that have affected the South-East Louisiana communities in recent years , 23. Theh during  and up t anxiety . These fCoalescing multiple areas of scientific and public health expertise, the DHW research consortia developed a Resilience Activation Framework (RAF) to model the multidimensional nature of resilience. Incorporating individual, community, and cultural parameters, the central premises of the model were that 1) most people and communities have the inherent capacity to be resilient and 2) these latent capacities can be activated through social support . Data obFrom design to dissemination, the benefits of engaging community partners are wide- ranging: from assuring research projects target practical and relevant research questions and innovative answers, to improving environmental health risk assessment, management and communication practices by generating locally relevant data, implementing community-driven interventions, and disseminating culturally- tailored information , 30, 31.


The Affordable Care Act (ACA) created incentives and opportunities to redesign health care to better address mental and behavioral health needs. The integration of behavioral health and primary care is increasingly viewed as an answer to address such needs, and it is advisable that evidence-based models and interventions be implemented whenever possible with fidelity. At the same time, there are few evidence-based models, especially beyond depression and anxiety, and thus further research and evaluation is needed. Resources being allocated to adoption of models of integrated behavioral health care (IBHC) should include quality improvement, evaluation, and translational research efforts using mixed methodology to enhance the evidence base for IBHC in the context of health care reform. This paper covers six key aspects of the evidence for IBHC, consistent with mental and behavioral health elements of the ACA related to infrastructure, payments, and workforce. The evidence for major IBHC models is summarized, as well as evidence for targeted populations and conditions, education and training, information technology, implementation, and cost and sustainability. The three component model (TCM) is also characterized by care management and enhanced mental health support, and explicitly includes the concept of a “prepared practice” Co-located collaborative care. The Strosahl While widely adopted as a collaborative care model, there is limited empirical evidence on this model, with a few exceptions. In the Primary Care Research in Substance Abuse and Mental Health for the Elderly (PRISM-E) study, co-located mental health and primary care for mental health/substance abuse was compared to enhanced referral to specialty mental health care The US Veterans Health Administration has embraced collaborative care, and has implemented a variety of models, including care management models targeted to depression Primary care in specialty mental health. Sometimes referred to as “reverse integration”, primary health care can be provided to patients with severe mental illness in specialty mental health settings, either through co-located primary care providers or care coordination. The VA system has also tested several reverse integration models 4.Past attempts have been made to determine “active ingredients” of IBHC – those structures and processes necessary and sufficient for effective IBHC. In a review from the Canadian Collaborative Mental Health Initiative (CCMHI), Craven and Bland The extent to which members of the care team collaborate  distinguishes many practices that provide integrated care. In a meta-analysis of studies evaluating the effects of interactive communication between primary care clinicians and specialists - defined as “direct, personal interaction with specialists… such as curbside consultations”  5.Decisions about care teams, care delivery settings and clinical processes to be implemented may also be influenced by the characteristics of the patient population served. While comprehensive services for all may be ideal, practical limitations dictate the need to narrow down the population to be targeted by IBHC services, and the types of clinical concerns to be managed internally versus referred out. The skills and training of the care team, needs of the patient population, available resources—and the evidence—inform the decision about targeted populations and conditions.Targeted Populations. The evidence base for IBHC addresses certain populations more than others, including older and middle age adults, veterans, and patients cared for in HMO settings, although the evidence is still limited to the disease contexts previously noted. For instance, both IMPACT and PROSPECT focused primarily on geriatric populations. In contrast, there is a limited amount of evidence on integrated care for children and adolescents. The Youth Partners-in-Care (YPIC) study was an RCT of the effects of a care management quality improvement intervention compared to enhanced usual care, in youth ages 13 to 21 with depression Targeted Conditions. The main body of evidence in IBHC concerns the management of depression, a pervasive and burdensome illness but by no means the only mental health problem confronted in primary care. Growing evidence exists in other mental health domains, such as panic disorder r = 0.63, p < 0.05) and amount of reduction in PTSD symptoms  Much of the most recent literature on IBHC involves management of multiple psychiatric and/or physical comorbidities. Many IBHC model features  reflect an instantiation of Wagner's Chronic Care Model Based on the IMPACT model, the Multifaceted Diabetes and Depression Program (MDDP) targets comorbid diabetes and depression in a low-income, predominantly Hispanic population There are mixed results regarding whether effective treatment of mental illness (in the context of IBHC) can lead to improved outcomes for comorbid chronic diseases. Longer term follow-up and/or the addition of more intensive chronic disease-specific intervention content may be required to observe an effect on these other outcomes. For instance, the Stepped Care for Affective Disorders and Musculoskeletal Pain (SCAMP) study implemented a twelve-week antidepressant therapy intervention in sequence with a six session pain management intervention (followed by a six month continuation phase) in patients with comorbid depression and musculoskeletal pain The TEAMCare intervention focused on patients with diabetes or coronary heart disease or hyperlipidemia and depression and utilized nurse case managers with specialist consultation working with primary care physicians in an attempt to increase adherence to medication and other self-care behaviors for both depression and co-morbid physical illnesses A broader focus on the range of behavioral health needs of patients in primary care 6.A critical component of IBHC is the workforce needed to deliver behavioral health services in collaboration with primary care. However, there is a looming workforce shortage of mental health professionals who can deliver quality behavioral services in primary care settings IBHC competencies and curriculum. In order to prepare for a new breed of mental health providers to work in primary care settings, there needs to be a foundation of knowledge, skills and professional values that support this training. However, mental health training has lagged behind other healthcare professions in defining core competencies for behavioral healthcare professionals. The Interprofessional Education Collaborative is one interdisciplinary organization whose goal is promote new models of team-based care and interprofessional communication for healthcare reform Creating team-based care training, clinical experience in primary care and quality improvement focus are essential for new models of care Current state and future needs in training and education. Even though there is an urgent call for training a new breed of mental health professionals, we lack data on the effective training models, adequate credentials, and team configurations 7.Another important structural component of IBHC is the health information technology (HIT) used to ensure care is “patient-centered, evidence-based, measurement-based, population-based, and accountable” Notably, HIT supports clinical decision support (CDS) with evidence based practice treatment algorithms. Intermountain Healthcare in Utah developed a model of mental health integration that combines evidence-based treatment with innovative informatics tools  for tracking patient progress and navigation of the system HIT can assist with better patient-centered care with greater focus on prevention while working to increase patient engagement and health literacy Many HIT-facilitated functions in IBHC, such as registry management and hospital follow-up performed by care managers or social workers, fall within the domain of care coordination. At present, many practices use homegrown care coordination systems separate from EHRs as reporting tools to accomplish the aforementioned tasks, sometimes in time-consuming ways, as current EHRs often do not offer features in a way that the clinics need to coordinate care Telemedicine. Telemedicine deserves special attention in a discussion of HIT for IBHC. Several telemedicine models have been studied The VHA tested the TEAM (Telemedicine Enhanced Antidepressant Management) intervention 8.Once having decided on structures, processes and targeted populations and conditions, and staffed your model with well-trained clinicians, the next critical step to be guided by the evidence is implementation. Research and evaluation concerning implementation and dissemination of IBHC is a growing area of focus Engaging stakeholders in planning and implementation is central to the Depression in Primary Care program (supported by the Robert Wood Johnson Foundation), which encourages engagement of six groups of stakeholders – 1) patients/consumers, 2) providers, 3) practice/delivery systems, 4) plans, 5) purchasers, and 6) populations/policies The Veteran Health Administration (VHA) Quality Enhancement Research Initiative (QUERI) is a methodology for quality improvement and mixed methods evaluation of implementation and dissemination of evidence-based practices The “Depression Improvement Across Minnesota, Offering a New Direction” (DIAMOND) project was a large scale implementation of IMPACT throughout the state of Minnesota, using a new payment mechanism agreed upon by participating payers. Six components of IBHC were implemented in DIAMOND: depression screening using the PHQ-9, tracking and monitoring with a patient registry, stepped care for depression, relapse prevention planning, care management, psychiatric consultation and supervision. The DIAMOND evaluation was a staggered implementation, multiple baseline design based on methods for practical clinical trials, with a focus on translation and dissemination outcomes Several publications on DIAMOND have focused on implementation. The “implementation chain” for DIAMOND starts with organization priority setting and reimbursement change, then developing change processes and practice systems (supported by training and facilitation resources), ultimately leading to improved outcomes at the patient level 9.Finally, while the evidence on paying for and sustaining IBHC has not yet caught up with the changes in reimbursement and financial models supported by the ACA, there is a literature on costs associated with IBHC. The sustainability of integrated care models can be tenuous One such initiative is SHAPE: Sustaining Healthcare Across integrated Primary care Effort, a 3 year evaluation of a global budget for integrated services. The sample includes six primary care practices on the Western Slope of Colorado and has three main objectives: 1)to determine if a global payment method will financially support and sustain behavioral health in primary care; 2) to understand how different payment models will affect clinical models of integration and their related costs; and 3) to test the real world application of a global methodology on primary care practices who have integrated behavioral health with the end goal to inform policy. The global payment model includes risk adjusted prospective payment for defined period, shared risk & accountability in budget and quality targets between practices and payer, and incentive opportunity for quality improvement in patient health outcomes. Results of this initiative are forthcoming Reimbursement. Healthcare providers are accountable for the care they deliver and payment models reward the delivery of effective care and good patient outcomes. A payment model associated with improved patient outcomes is the Washington state Mental Health Integration Program The Health Information Technology for Economic and Clinical Health (HITECH) Act invests $26 billion in HIT by providing financial incentives for adoption of EHRs. This legislation seeks to promote the spread of EHRs to improve healthcare, with implementation. Medicare and Medicaid provide incentives coupled with penalties beginning in this year for providers who fail to adopt EHRs that meet meaningful use standards These goals share substantial overlap with the principles and activities characteristic of effective IBHPC and demonstrate the need to pair HIT with appropriate service delivery models. A significant gap remains in our understanding of how to sustain the integrated care interventions demonstrated in these relatively richly resourced environments in small to medium sized, independent primary care practices. This is where the ACA can be most beneficial – creating opportunities to pay for behavioral health specialists and care managers. Emerging models of pay for performance and accountable care organizations (ACOs) are dramatically restructuring the incentives for chronic disease care delivery, and may serve as a boon for attempts to implement IBHC sustainably. In addition, further research is needed at multiple levels within various systems to demonstrate the impact of IBHC on cost savings to determine which interventions or models of care result in reduced emergency room visits and hospitalizations, reduced need over time for specialty medical care, improved efficiency within the clinical setting, and overall improved population health in areas of mental health, health behavior change, and substance abuse and dependence. Other ways of demonstrating the value of IBHC has to do with examinations of improved job satisfaction and decreased burnout within primary care teams 10.In summary, there is strong evidence supporting IBHC, and meta-analyses show that IBHC can lead to better outcomes for many patients – especially those with depression. A majority of studies have focused on outcomes in patients with a mental health diagnosis, and on IBHC approaches involving care management for depression. However, this is quickly changing, and evidence for other IBHC models for a variety of behavioral health concerns is emerging. Screening and treatment for depression and substance abuse have received the most rigorous evaluation through randomized controlled trials, and are thus backed by the strongest empirical support. Common elements across studies include standardized screening standards for identification of patients; clinical care management services and consistent follow-up; medical monitoring and medications; and brief behavioral health treatment within the primary care setting. With new evidence emerging of the equivalent efficacy of behavioral treatments to medication, availability of IBHC is likely to gain importance More evidence is needed for payment models and practice improvement in IBHC, training and workforce development, and on strategies for implementation and large scale dissemination in real-world settings with complex patient populations. Classic randomized trial designs may not fit with measuring such dynamic and complex interventions, which has resulted in narrowly focused research on the establishment of only small numbers of short-lived programs that show minimal impact on healthcare policy and funding. The evidence-based foundation for IBHC is hindered by narrow definitions of quality empirical research. New research paradigms are needed to accommodate comprehensive and complex primary care questions about essential elements, effective interventions, and implementation strategies for IBHC. Innovative techniques such as mixed quantitative and qualitative methods, pragmatic trials and other process-observational approaches have the potential to define more comprehensively what constitutes behavioral healthcare, translate key components of IBHC within local healthcare settings, and determine the effectiveness of such approaches.The ACA has great potential to promote a global vision of offering whole person-centered care and provide opportunity for integrated behavioral health care to become embedded in primary care. It is time for the behavioral health field to not only advocate for change within the system, but to redefine itself as a central player in healthcare as a whole, rather than a distinct and separate subspecialty.


Recent years have seen increasing attention on posttraumatic stress disorder (PTSD) research. While research has largely focused on the dichotomy between patients diagnosed with mental disorders and healthy controls — in other words, investigations at the level of diagnoses — recent work has focused on psychopathology symptoms. Symptomics research in the area of PTSD has been scarce so far, although several studies have focused on investigating the network structures of PTSD symptoms. The present special issue of EJPT adds to the literature by curating additional PTSD network studies, each looking at a different aspect of PTSD. We hope that this special issue encourages researchers to conceptualize and model PTSD data from a network perspective, which arguably has the potential to inform and improve the efficacy of therapeutic interventions. Armour, Műllerová, & Elhai, While research has largely focused on the dichotomy between patients diagnosed with mental disorders and healthy controls – in other words, investigations at the level of diagnoses – recent work has focused on psychopathology symptoms. One reason for this is that disorder-level data are often highly heterogeneous: patients suffering from mental disorders such as PTSD or depression have many different symptom presentations (Fried & Nesse, individual symptoms with important variables such as risk factors, biomarkers, impairment of functioning, and treatment response (Bentall et al., The relationship of The analysis of the potentially causal relations among symptoms in symptom networks (Borsboom, Gaining better understanding of psychopathology by investigating personalized processes at the level of individuals instead of heterogeneous groups of patients (Fisher & Boswell, Symptom-based analyses are on the rise for many disorders such as major depression (see review; Fried & Nesse, EJPT adds to the literature by curating four additional PTSD network studies, each looking at a different aspect of PTSD.Symptomics research in the area of PTSD has been scarce so far, although several studies have focused on investigating the network structures of PTSD symptoms (Afzali et al., 2.In ‘Symptoms of posttraumatic stress disorder in a clinical sample of refugees: a network analysis’, Spiller and colleagues (Spiller et al., In the paper ‘Making connections: exploring the centrality of posttraumatic stress symptoms and covariates after a terrorist attack’, Skogbrott Birkeland and Heir  identifiGlück, Knefel, and Lueger-Schuster  in theirBayesian statistics in the field of psychotraumatology (Van de Schoot, Schalken, & Olff, Finally, in a sample of 179 US adult survivors of childhood sexual abuse, McNally, Heeren, and Robinaugh  in ‘A Ba3.The above papers represent a significant contribution to the literature on posttraumatic stress, as viewed from a symptom-level perspective. We hope that this special issue encourages researchers to conceptualize and model PTSD data from a network perspective, which arguably has the potential to inform and improve the efficacy of therapeutic interventions (Borsboom, However, several crucial challenges still lie ahead, some of which are described in detail elsewhere (Fried & Cramer, We believe that the network approach to psychopathology has been embraced so quickly by the community because it reflects how patients and clinicians think about many mental disorders: as dynamic systems of causal influences and vicious circles. Interestingly, this lies in contrast with the frameworks adopted by the DSM and ICD that understand symptoms as passive consequences of underlying disorders. We are looking forward to seeing whether the analysis of individual symptoms and causal dynamics can lead to significant changes in how mental disorders are measured, modelled, categorized, and diagnosed.


Although the public health system in Haiti has beenimproved since the earthquake, emergency response and health recovery funding has largelyfocused on new and acute threats such as Zika virus.10 Moreover, the health-care delivery infrastructure remains fragile,with limited coverage of primary care services, suboptimal health-care performance, andexcessive health risk and vulnerability for the Haitian population. It is in this contextthat the Supplement, entitled “Public Health Progress in Haiti,” wasdeveloped. The reports enclosed span HIV, TB, malaria, cholera, immunizations, rabies,water, sanitation and hygiene, and lymphatic filariasis, and also address notifiabledisease surveillance reporting and national laboratory capacity.11–20 Collectively,they appraise some of the key programs and services that have been the focus ofpostearthquake response and recovery planning and which have central roles informingcurrent and future strengthening and prioritization within the health sector.Although the attention of the Haitian public and international community has understandablyturned to the recurrent political challenges facing the country and recovery from HurricaneMathew, it is important that public health stakeholders take stock of progress made,remaining gaps, and fundamental public health priorities. In the past year, the globalcommunity has assessed progress toward the Millennium Development Goals (MDGs) andestablished new health targets under the Sustainable Development Goals framework.11Public health laboratory capacity has been broadened and sustained, benefitting bothdisease surveillance and response, and clinical services.12 TB case notification and detection rates have increased, inpart due to expansion of TB laboratory diagnostics and other case detectionefforts.13 HIV clinicalsurveillance efforts have advanced, leveraging national patient-level information systemsto enable robust analyses of the clinical cascade, including retention on HIVantiretroviral treatment—an unprecedented achievement for a country facing ageneralized epidemic.14 Collaborativeresearch in lymphatic filariasis and malaria has enabled progress toward and underpinnedcommitments to elimination goals on both fronts.15,16 The national immunization program has advanced specificelimination goals while introducing new vaccines and strengthening surveillance andresponse for vaccine-preventable diseases.17 Novel rabies surveillance efforts have better defined burden of diseaseand enabled prevention services in the country.18 Targeted research on and innovative collaboration promoting accessto safe water has informed national strategic planning for control of cholera and otherdiarrheal diseases.19 Finally, efforts toexpand coverage of the oral cholera vaccine in a targeted manner have contributed toongoing national cholera elimination efforts in the face of challenges recently heightenedby Hurricane Mathew20,21  health sectorstrategic plan, and the assessments and prioritization exercises that were performed duringthe early phases of emergency response planning, all remain key reference points and willbe touched on throughout the various articles presented herein.26 Although broad and diverse, these reports do not addressall important aspects of public health, such as maternal and child health, in depth.However, our hope is that, taken together, these reports will help to illuminate some ofthe tremendous public health gains made, and lessons learned, through the leadership of theGOH in close partnership with national and international partners.There are several relevant frameworks for considering the current status of health servicesand public health programs in Haiti, including those used by the Pan American HealthOrganization and the World Health Organization, as well as the essential public healthservices which have been developed to serve as a complementary paradigm with a moreexplicit focus on public health aspects.27 However, from2005 to present, and coinciding both with the introduction of major global health financinginitiatives from the Global Fund to Fight AIDS, Tuberculosis and Malaria and the U.S.President’s Emergency Plan for AIDS Relief, as well as the earthquake and choleraepidemic in 2010, there is evidence of substantial displacement of host governmentfinancing of the health sector due to external financial support, as well as the slowrecovery of GOH revenues postearthquake.28 In the past few years, while total health spending has increased, GOHhealth allocations have decreased to < 5% of the national budget,28 despite the efforts of the Ministry ofPublic Health and Population (MSPP) to seek and advocate for increased health financingacross other GOH institutions. Even during recent stretches of Haitian history with similarpolitical difficulties, health allocations by the GOH remained closer to the 15%international benchmark,29 suggestinggreater effort is needed from within the GOH, civil society, and the internationalcommunity to increase emphasis on the importance of increasing and sustaining healthallocations. The 2015 health financing conference convened by MSPP and health donors was astep in this direction, but the creative proposals developed need to be carried forth bythe new government.2Two issues remain central to the challenges and opportunities facing Haiti’s healthsector today: financing and governance. As official data from the national health accountsvividly portray, as recently as 2004, the GOH allocated > 15% of total nationalexpenditures to health.30 Such limitations can be addressedsystematically with preservice educational capacity, novel health financing, and robustgovernance capacity within the public health sector. Only in this manner will the reputed“Republic of NGO’s”31 be able to establish health services and programs with a public sectorbackbone to promote stability and continuity, and, above all, support national efforts toprovide universal access to health care. Only this will improve the health of Haitians whocontinue to face the worst health metrics in the Western Hemisphere.32Governance is another crucial public health functional domain which, although hard todefine and measure, is essential to long-term public health progress. Governance and healthfinancing are integrally intertwined, as stable financial support to hire and retainadequate human resources for health at all levels is a prerequisite for institutionalcapacity building and stepwise gains in sustainability. Entire units and programs withinMSPP remain dependent on external donor financing to sustain adequate staffing levels andto prevent the loss of skilled workforce (“brain drain”).Although addressing country ownership for financing and governance is critical for ensuringthat progress across public health programs in postearthquake Haiti is sustained, strongerpartnerships between international and indigenous organizations are still needed to solvethe greatest public health challenges. These include increasing access to clean water andimproved sanitation; eliminating cholera; achieving and sustaining 90% immunizationcoverage for all routinely administered childhood vaccines; and ensuring supply chain forHIV antiretroviral treatment, essential cholera response commodities-like oral rehydrationsolution, and robust second-line drug regimens for treatment of multidrug-resistant TB.33 Haiti’s recent experiences should both inform these effortsin other countries and regions, and ensure ongoing and legitimate partnership in the yearsahead. The public health progress characterized by the reports in this Supplement should because for confidence and for hope that such critical efforts can and will continue evenwithout the extraordinary impetus of disasters and emergencies, even as Haiti continues itsrecovery from yet another devastating storm. Given the existing and longstandingsocioeconomic realities, the GOH and international donor community must be pragmatic andincremental in considering the issue of sustainability in this context.34,35 Focus on maintaining essentialpublic health services, with emphasis on surveillance, laboratory capabilities, workforcecapacity development, and emergency preparedness and response, while shoring up key healthsystem building blocks such as health financing and governance, will define a pathway tomaintain the hard-won momentum that has been achieved, and which should not besquandered.The global health community is developing new initiatives to more effectively prepare foremerging public health threats and emergencies.


The provision of OGs is increasingly seen as an important strategy to realize public health agendas promoting habitual physical activity. A systematic review was conducted to synthesize characteristics of OG and OG users’ experiences and perceptions in different cultural contexts; (2) Methods: Online searches of multidisciplinary databases were conducted in health, sport and recreation, and urban planning disciplines. Characteristics of OGs were synthesized by integrating evidence from quantitative, qualitative, and mix-methods studies. The experiences and perceptions of OG users from both qualitative data and survey responses were synthesized through framework analysis; (3) Results: Nine studies met the inclusion criteria . None were excluded on the basis of quality. OGs mainly serve adult and older adult population groups. Their size, design, and instructional support vary across studies. The inclusion of functional types of equipment did not have a unified standard. Regarding experiences and perceptions of OGs, five major themes emerged: “health”, “social connectedness”, “affordable”, “support”, and “design and promotion”; (4) Conclusions: The OG characteristics synthesis guides the direction in further studies regarding exploration of design parameters. The qualitative and quantitative synthesis revealed that health was a central theme of users’ experiences. OGs are also spaces where community-dwellers can find social connectedness while participating in structured physical activity at no cost. Findings from this review create knowledge support for OG as environmental infrastructure for further research and facilitate the understanding of users’ experiences and perceptions of OGs in different cultural contexts. The promotion of physical activity is an important public health agenda, as it is well documented that adequate physical activity is vital for disease prevention and health promotion . TraditiThe social ecological model suggests that health behavior  is a result of inter-relationships between individuals and their social and physical environment . Based oAn OG is environmental infrastructure in an open space or an area in a park that consists of a cluster of weather-resistant exercise machines or exercise stations that assist individuals to perform physical activity ,12,13. STo provide a more comprehensive understanding of the research questions that this review sought to address, both qualitative and quantitative evidence, including qualitative, quantitative, and mixed-methods studies, was chosen to be included in the review. This type of review is useful when there is limited research on the topic being investigated. Online searches of the following English and Chinese multidisciplinary databases covering health, sport and recreation, and urban planning were conducted: British Nursing Index (BNI), Cumulative Index to Nursing and Allied Health Literature (CINAHL), PubMed, Medline, PsycINFO, SPORTdiscus, Environmental Science and Pollution Research (ESPR), and the China journals full-text database (CNKI). All potentially relevant literature, both published and unpublished, with no date restrictions, was searched. The bibliographies of the identified papers were examined for additional references. Field researchers were contacted to identify grey literature. The main search was completed in October 2017. A topic-oriented search approach was adopted. The search terms included a combination of key words related to OGs . Search strategies were refined for each database. A back-and-forward tracking procedure was performed to identify additional relevant articles. Articles were first screened by abstract and title, 36 records were retrieved, and 12 studies were then excluded after closer examinations. A total of 24 articles were assessed for eligibility in full-text. Studies were included if they (1) Investigated OG as the main focus; (2) Explored the views and perceptions of OGs either quantitatively or qualitatively. Quantitative studies, qualitative studies, and mixed-methods studies were eligible for inclusion. Both peer-reviewed journal articles and grey research literature  were eligible for inclusion. Studies were excluded if they (1) mainly explored physical activity experiences in green spaces or parks; or (2) contained insufficient data for synthesis. The study selection and data extraction followed a three-stage process: (1) database searching; (2) screening based on title and abstract using inclusion and exclusion criteria; and (3) selecting papers for review and data extraction. Two reviewers (Janet Lok Chun Lee (JLC), Temmy Lee Ting Lo (TLT)) were involved in the data selection and data extraction process to improve accuracy and avoid bias. Database searching, paper selection, and data extraction were conducted by JLC. Paper selection and data extraction were cross-validated by TLT. Data were extracted using a customized Excel spreadsheet. Extracted information included year of publication, sampling country, study aim, participant characteristics, sample size, study design, sampling method, data credibility method, analysis method, and results. Disagreements were resolved by consensus until full agreement was reached.κ, and a high level of agreement was reached (κ = 0.82). The quality of the quantitative studies was assessed using the STROBE  checklist [The criteria for quality assessment were based on the Critical Appraisal Skills Program checklist . The chehecklist . Rating hecklist . No studSynthesizing characteristics of OGs. Textual and numerical evidence of the characteristics of OGs from quantitative, qualitative, and mixed-methods studies were extracted and synthesized. Synthesizing experiences and perceptions of OGs. The experiences and perceptions on OGs from both qualitative data and survey responses were synthesized through framework analysis developed by Ritchie, Lewis . FirstlyNine studies published between 2012 and 2017 were included in the systematic review  rehabilitation; (2) physical health; (3) mental health; (4) fitness; (5) gain strength; (6) improve mood; (7) pursuit of health; (8) prevention; and (9) weight reduction.The health theme was found in all of the reviewed studies. Participants expressed that using the equipment at OGs helped to treat health issues including frozen shoulder , post-suQuantitative evidence showed 39% of the survey respondents of one study  indicateThe theme of social connectedness included the following subthemes: (1) new friendship; (2) benefits to family; (3) socialization; and (4) encouragement of other people.Social connectedness was found in most studies. Participants expressed that users of OGs became friends and they liked the idea that they could exercise and also chat with their friends and get encouragement from others ,28,29,30The subtheme of family was found in one study, in which a participant said she liked the idea that the OG allowed her to bring her children with her when she was doing exercise. She also saw it as a good role-modeling opportunity, as her children had a chance to see her being active . The theme of affordable was found in two studies. OG is a free facility for the public. A participant in one study expressed that she and her family could not afford a paid gym and the OG was her only opportunity to receive resistance training . The parThis theme was supported by survey data, in which survey respondents rated on average 3.77 (SD = 1.63) on a seven-point Likert-scale on the statement “I only do this type of exercise because the equipment is freely available” . The support theme included the following subthemes: (1) maintenance and management; and (2) inadequate instrumental support.Maintenance and management were recurring subthemes in most of the reviewed studies ,28,29. PParticipants in a few studies mentioned that they would like to have more instrumental support, such as having an instructor teaching them how to use the equipment, an exercise class with an instructor, or more instructions about the facilities ,27,30. The design and promotion theme included the following subthemes: (1) quantity and variety of equipment; (2) safety; (3) advertisement; (4) shade; and (5) location close to attractions.The quantity and variety of equipment were recurring subthemes. Participants were skeptical about whether the available circuits of equipment provided sufficient opportunities to exercise all parts of the body  and exprQuantitative evidence showed that survey respondents of one study  rated onThe subthemes of shade and safety were related to facility design, while the subtheme of location close to attractions was related to landscape architecture design. One participant mentioned feeling uncomfortable exercising when there was strong sunlight . Survey evidences showed that 87% of the survey respondents of one study  indicateThe current study systematically reviewed and integrated evidence from mixed-methods studies. Based on the inclusion criteria, nine studies were included in the review. The main objectives of the study were to support knowledge of OGs and identify recurring themes related to experiences and perceptions of OGs through qualitative and quantitative data synthesis.An OG is important environmental infrastructure with the potential to influence a larger number of community dwellers to meet public health guidelines on physical activity in public settings . The synSynthesis of characteristics of OGs of the included studies shows that while some OGs in this review were primarily used by older adults ,28,29,30In short, based on this synthesis, OGs of the included studies mainly serve adult and older adult groups. They are mostly under-supervised. The types of functional equipment available at OGs vary across studies and do not seem to have a unifying serving purpose or role. Regarding users’ experiences and perceptions of OGs, the theme of “health” was central to the experiences of OG users and residents in the neighborhoods in which OGs were located. This theme is supported by both qualitative and quantitative evidences. Participants used OGs for pursuing health, weight reduction, strengthening their physical health, and restoring health. Moreover, the health experience of using an OG was similar to the park visitation experience of the older population group. A quantitative park study that used a survey as a research instrument reported similar findings, with older park users ascribing their visits to parks as mostly health-related . It is iThe second most prominent and recurring theme regarding the experience of OG users was social connectedness. Social interaction with other users and the possibility of bringing other family members to the facility in a park environment were subthemes related to OG users’ experience. The theme of social connectedness provides preliminary grounds to establish further research on OG-based physical activity health promotion interventions, as a study that investigated the motivators for physical activity showed that people prefer interventions with a social component . A previRegarding perceptions of OGs, being affordable was a recurring attribute of OGs recognized by participants in the reviewed studies. This theme is also supported by quantitative evidence by a survey . This fiSimilar to other research , which fThe study participants’ perceptions of a lack of management and maintenance of OGs affecting usage is similar to the findings of previous environmental physical activity research . The finThe quantity and variety of equipment was a prominent subtheme under the main theme “Design and Promotion.” Both qualitative and quantitative evidence is in support of the government providing a higher quantity of equipment in parks ,29. AparTo the best of our knowledge, this is the first study that integrates evidence from quantitative studies, qualitative studies, and mixed-methods studies on OGs in open environments. Several limitations should be acknowledged when interpreting the findings of this review. First, the studies included are not OG interventional studies, so information gathered for the OG characteristics synthesis might not be comprehensive enough. Second, non-published grey research literature was included. Non-published grey literature and most of the studies included in our review did not apply strategies that ensure data credibility , and the quality of the review findings is thus compromised. Third, some studies included in this review were mixed-methods studies. Although these studies conducted interviews with neighborhood residents and facility users on their experience of or views on OG, they only reported the themes identified from the interviews by content analysis; supporting quotations were not reported, which made synthesis difficult and affected the comprehensiveness of the secondary data analysis. The findings of this review will not directly help with a specific decision in OG-related research, but this review adds to knowledge of this kind of infrastructure in public open space environments.Understanding OGs is an emerging and promising area of research. As this environmental intervention has the potential to affect population health, this review provides a valuable overview of evidence from disparate studies. OGs take slightly different forms in different countries. This may be the first review to attempt to synthesize the design, primary user group, and terminology used for OGs, and to give an overview of how users and neighborhood residents from different cultural backgrounds perceive this kind of physical activity–related environmental infrastructure. The current review included studies from both Asia  and Western countries , which increases the generalizability of the findings. Both published and non-published research literature were included in the review, reducing publication bias. Synthesizing the design, primary-user group, and operation of OGs has created knowledge support for this kind of environmental infrastructure. Findings suggest that further studies on exploration of the design parameter and instructional support of OGs are needed. The qualitative and quantitative synthesis reveals that health is a central theme in users’ experience. OGs are also public spaces where community-dwellers can find social connectedness while performing structured physical activity at no-cost. The current review can guide the direction of further research into the functional roles of OGs in society. The results may also inform further interventional studies related to physical activity health promotion based on social-ecological theory. Further research should also consider and address the methodological limitations of the currently published findings.