Food literacy education at senior secondary school can provide both immediate and long-term benefits for adolescents. The exploration of multiple stakeholder groups’ opinions regarding the importance, roles, and challenges of school food literacy education, and their suggestions for its improvement, will help the design and execution of future food literacy-related curricula and programmes. This study explored a broad range of Australian and international food, health, and education professionals’ opinions regarding senior secondary school food literacy education through an online survey. One hundred and fifty-five food, health, and education professionals completed this survey between April and October 2017. Overall, the respondents strongly supported the need for food literacy education for senior secondary school students. Their suggestions for improving this form of education included: incorporation of relevant and up-to-date content, the presence of strong practical components, offering food literacy as compulsory subjects or the incorporation of food literacy concepts into compulsory core subjects. Moreover, they proposed the active contribution of both internal and external stakeholders in the planning and delivery of this education to upgrade its quality and relevance. Overall, the findings suggest that a wide range of food, health, and education professionals are highly supportive of senior secondary school food literacy education and their constructive suggestions should be considered in school food literacy education enhancement efforts. Education authorities should seek ways of involving different stakeholders, including food-related professionals, in the design and delivery of food literacy education, and future studies should explore the best mechanisms for such involvement. Food literacy is an emerging concept that has been heavily influenced by health professionals, nutritionists, and home economists and fundamentally aims at achieving personal health-related goals ,2,3,4,5.In many educational contexts around the world, some components of food literacy such as food and nutrition knowledge and food planning and preparation skills, have been taught to adolescents through home economics and other related subjects for over 100 years ,12. In rSchools have been identified as ‘social complex adaptive systems’ and consist of diverse agents . Thus, ePrevious overseas and Australian researchers have explored some of these stakeholders’ opinions regarding various aspects of school food literacy education ,30,33,38The findings of these qualitative studies ,41,42 weThemes identified in the two previous qualitative studies conducted by the authors ,41,42 inRespondents were asked to rate their agreement with 10 statements related to the importance of food literacy for senior secondary school students. Five category rating scales were used (strongly agree (coded as 1), agree (coded as 2), no idea/ not sure (coded as 3), disagree (coded as 4), strongly disagree (coded as 5)). After inspection of the data distribution, it was decided to aggregate these categories into ‘agree’ (codes 1 and 2) and ‘disagree’  to facilitate the interpretation of cross-tabulation analyses.Respondents were asked to rate their agreement with the inclusion of different food-related topics in the food literacy curriculum for senior secondary school students. A list of 35 topics was presented under four sections. The five category rating scales were employed (as above) and similar category aggregation was used to facilitate the interpretation of cross-tabulation analyses. Cronbach’s alpha for the items in the four sections were: 0.68 (history of food), 0.82 (the food system), 0.82 (the science of food and influences on food consumption), and 0.87 , indicating acceptable internal consistency reliability .The respondents were asked to rate their agreement with seven statements about students’ activities and assessment-related tasks. Again, five category rating scales were employed (as above) and similar category aggregation was used to facilitate the interpretation of cross-tabulation analyses.The respondents rated their agreement with 14 statements related to barriers and challenges for food literacy education for senior secondary school students. The same scale categories and aggregations were used as in the previous sections. Then, the respondents were asked ‘Are there any other barriers for food literacy education for senior secondary school students?’ Space was provided for them to record their answers verbatim. The respondents were asked ‘Please suggest how the quality and relevance of school food literacy education can be improved’ to get a better understanding of food, health, and education professionals’ opinions of school food literacy education and to confirm their ratings of different aspects of this form of education  ,44. AgaiPost-school qualification(s) ;Area(s) of food-related experience ;Years worked/involved in food-related area(s) ; Current roles(s) , 2 = health professionals (HP), 3 = school teachers (TH));Age ;Gender ;Current residence . The professional and demographic characteristics of the respondents were obtained through questions about the following areas:http://deakinhealth.qualtrics.com). The second author completed the online survey as a trial and suggested a few changes to the wording and flow of questions, and these suggestions were incorporated into the final survey questionnaire. A link to the plain language statement was included in the survey. An anonymous link to the final version of the questionnaire was used for the data collection. The survey was conducted in April–October 2017. Ethics approval for this study was obtained from Deakin University Health Faculty Ethics Advisory group (HEAG-H 15_2017).The content validity of the survey instrument was determined through review of the instrument by three food-related professionals who had experience in mixed-method research . The queThree strategies were employed to recruit respondents for this survey. Strategy 1: Twenty-five organisations that deal with food-related areas  in Australia and overseas were identified through discussions between the authors. The heads, or suitable alternative ranking personal, of these organisations were approached and requested to advertise or distribute the survey invitation flyer among their members. Strategy 2: Food and nutrition-related professionals  attached to universities and other professional organisations in Australia and overseas were identified through a thorough web search, and their email addresses were obtained through publicly-available web sites. Furthermore, email addresses of a group of food technologists and home economics professionals were obtained from two conference participants lists. An email invitation, along with the survey link, was sent to these professionals.Strategy 3: Social media platforms  were employed to increase the reach of the survey among potential participants. Australian and overseas Facebook groups related to food, nutrition, health, gardening and farming, agriculture and horticulture, hospitality, and food education professionals and teachers were identified. Ten different Facebook advertisements containing the survey invitation and link were designed to attract the different target groups and then these adverts were shared among the previously identified Facebook groups. In addition, three rounds of paid Facebook advertisements were employed . The preliminary analysis of the respondents’ demographic profile revealed that the sample lacks marketing professionals. Therefore, in collaboration with a senior professional in marketing education, a group of junior and senior food and beverage marketing managers  in Australia was identified. A short message containing the link to the survey was sent to these identified professionals via the LinkedIn platform. The survey invitation was also sent to a senior home economics professional in Australia who was asked to distribute the survey to her professional network. This professional forwarded the survey invitation to both Australian and overseas home economics professionals and teachers using Twitter. Except for strategy 2 and the LinkedIn invitations, the authors did not send the survey invitations directly to the potential professionals . Therefore, the total number of professionals who received the survey invitation was unable to be obtained by the authors.p value of less than 0.01 was selected as the level of significance, to guard against type 1 error [Quantitative analyses: The responses to the closed answer questions were analysed using SPSS statistical software . Cross tabulation (Chi-square) analyses were performed to examine bivariate associations between several categorical variables , experience of food-related areas , age (<40 years and ≥40 years), gender , type of educational qualification , residence ), and the respondents’ opinions of different aspects of senior secondary school food literacy education . In view of the use of multiple significance tests, a  1 error .Qualitative analyses: One hundred professionals provided 155 written responses to the question ‘Please suggest how the quality and relevance of school food literacy education can be improved’. These responses were extracted from the Qualtrics online platform and uploaded to NVivo , and analysed using the template analysis technique ,48. The One hundred and fifty-five food, health, and education professionals completed the survey out of the 282 professionals who commenced the survey, giving a completion rate of 55% . The demographic and professional backgrounds of the respondents are shown below in Nearly all the respondents (99%) agreed that ‘There should be continuity between primary and secondary school food literacy education’. More than 90% (92–94%) agreed with the need for, and roles of, senior secondary school food literacy education . Over thThe majority of professionals agreed with the inclusion of ‘causes and prevention of food wastage’ (98%), followed by ‘planning and preparation of food’ and ‘safe food handling’ (97%) topics in the senior secondary school food literacy curriculum. Between 90–95% of the respondents agreed with the inclusion of 15 out of the remaining 32 topics . BetweenThe majority of the respondents (>90%) agreed with the importance of practical lessons in senior secondary school food literacy education, including cooking based practicals and excursions . More thMore than 80% of respondents agreed with ‘competition with other subjects’, ‘exposure of students to conflicting food and nutrition-related information through different media’, and ‘perceived low academic status of subject by school managements, parents, and students’ as barriers facing senior secondary school food literacy education . Lower, Thirty-two respondents answered the question: ‘Are there any other barriers for food literacy education for senior secondary school students?’ The most common barriers they mentioned included ‘low awareness among students and general society about the importance of food literacy education’, ‘inadequate support from policy makers to improve food literacy education’, and ‘inadequacy of food literacy subjects in junior school years’.p < 0.001).More school teachers (55%) agreed that ‘It is difficult to include food literacy concepts in other senior secondary school subjects’ compared to food industry professionals (28%) and health professionals (21%) . Similarly, fewer men (56%) agreed with the inclusion of ‘Indigenous food practices’ compared to women (86%) .Fewer food industry professionals (53%) agreed with the inclusion of ‘Indigenous food practices’ in senior secondary school food literacy curriculum compared to health professionals (84%) and teachers (94%) Improving the status of food literacy subjects: Twenty-two respondents suggested that food literacy subjects need to be given proper value and recognition among other senior secondary school subjects. Seven of them suggested that offering food literacy subjects as compulsory and core subjects for senior secondary school students would enhance the status and value of food literacy subjects.Five respondents commented that food literacy education should be started in primary school and continue throughout secondary school.“Educational outcomes must include practical food skills to enable students to plan, shop and cook nutritious balanced meals for the health of themselves and their families, as well as the critical thinking skills to analyse food and nutrition myths, and misleading marketing.”Incorporate content that is relevant and up-to-date: Nineteen respondents mentioned that food literacy subjects should be framed in a way that provides knowledge and skills that are relevant and useful for the students. The knowledge and skills that they mentioned included: food planning and preparation, understanding the role of food in health, food trends, and present and upcoming food-related problems. For instance:“Improving the status of the subject but showing how food is based on the sciences and that it is woven into every aspect of our lives and can be used to deliver all subjects in education.”(ID 119/Teacher)Moreover, they mentioned that the subject content needs be updated regularly and should be based on current, emerging, and evidence-based information.“A combination of classroom and practical activities that the students can be involved in to stimulate interest and knowledge on food literacy.”Have a strong practical component: Ten respondents emphasised that food literacy subjects should have a strong practical component that enables students to develop their food-related skills.n = 26) wrote about the teachers. They believed that teachers need to have a sound understanding of food literacy concepts and present food-related issues. They suggested recruiting well-qualified professionals to the food literacy teaching profession and providing continuous professional development opportunities to acquire up-to-date food literacy knowledge and skills.“Regular professional forums aimed to improve knowledge and skills of practising teachers.” Internal stakeholders’ involvement in food literacy education: Thirty-seven respondents (38 comments) suggested having active involvement and support from school management, teachers, students, and parents for improvement of quality and relevance of food literacy education. The majority of them (“Administration to place a significant importance in the subject.” (ID 124/Teacher)Four respondents mentioned that opportunities should be given to senior secondary school students to contribute to food literacy curriculum development and active involvement in school food-related activities such as school canteen menu design.“Involve students in supporting healthier food environment at school—e.g., food waste management, healthier foods at canteens, in vending machines, kitchen gardens, food swaps etc.” Seven respondents (seven comments) proposed that school management should acknowledge the importance of food literacy subjects and allocate adequate resources accordingly.“The school environment needs to reflect what is taught in the classroom so needs a whole school commitment to a healthy eating environment. Food activities such as school gardens, produce fairs , healthy fund raising activities can support.” “More time for prep and time to carry out the lessons.” (ID 119/Teacher)Allocation of more resources for food literacy subjects: Twenty-six respondents (27 comments) recommended that more resources should be allocated for food literacy education. The resources they mentioned included online platforms and apps with food literacy-related updated information and activities for students and teachers, more funding, adequate time allocation for food literacy subjects in school timetables, improved infrastructure, and a facilitating school environment that reinforces the facts students learn.“Partner with university programs to show the future pathways.” Seventeen respondents (18 comments) mentioned several ways of eliciting support from outside food professionals and organisations to improve the quality and relevance of senior secondary school food literacy education. One suggestion was the exploration and development of career pathways for students who take food literacy subjects in collaboration with food-related professionals and organisations such as farmers, nutritionists, and universities and Technical and Further Education Institutes (TAFEs).“The curriculum must be informed by nutrition/food science professionals who also understand relevant food issues and nutritional needs for adolescents.” It was also suggested that input from food-related professionals in food literacy curricula development should be sought. As an example, one respondent wrote:“Use production classes to cook for community group. Have members of the community come in and pair up with students to cook and talk with students one on one.” (ID 66/Teacher)Other suggestions included the involvement of community food movements/groups, food industry professionals, and hospitality professionals in delivering some aspects of school food literacy programmes..Some important findings arise out of this study and they are discussed briefly in this sectionBoth the quantitative and qualitative findings showed considerable support for offering food literacy-related subjects across all the school grades and offering them as compulsory subjects. For students to gain value from food literacy education, it needs to be offered from their early years of school or even earlier  ,42. StudFood literacy concepts can be successfully integrated into compulsory subjects such as science and maths ,51,52 anThere was widespread support for the inclusion of most of the listed topics in the senior secondary school food literacy curriculum. However, there was less enthusiasm for history-related topics, despite their importance in understanding the transition stages of the food system ,55. As iCurriculum overload (or competition with other subjects) is a major challenge faced by food literacy education ,27,29. AAnother challenge associated with food literacy education is the exposure of students to conflicting food and nutrition information through different media. Previous studies have also found that exposure of adolescents to food marketing via different media is associated with unhealthy eating patterns such as increased snacking and junk food consumption ,57,58. TPerceived low academic status of food literacy subjects by school management, parents, and students is another barrier to food literacy education ,29. As sTeachers play an important role in the successful delivery of food literacy education to students. They should be passionate about food literacy education and they should have a sound understanding of food literacy concepts and food-related issues. The provision of continuous professional development (CPD) opportunities for teachers was suggested as a way of achieving this. The previous studies of the authors ,59 complInviting the services of various food and nutrition experts such as farmers, food technologists, nutritionists, dietitians, food activists, and career consultants  as guest speakers could assist in improving the quality and relevance of senior secondary school food literacy education. Furthermore, these stakeholders should be involved in food literacy curriculum design. This would help to make food literacy-related subjects relevant to students’ personal and social lives and future careers.These findings have some implications for the development and delivery of senior secondary school food literacy curricula and programmes in Australia and elsewhere. The findings of this study suggested that the broad range of food system professionals and health professionals have sound understanding of how senior secondary school food literacy-related education can be improved. Both higher level  and lower level  food literacy education design and implementation bodies should try to involve these professionals in the design and delivery of school food literacy education. However, any involvement of these external stakeholders needs to be properly planned to avoid problems such as the inclusion of other incompatible agendas  and loss of control over the types of information delivered to students. The education authorities and curriculum leaders should consider the suggestions provided by the professionals in this study in future secondary school food literacy-related curricula and programme execution.The findings show the importance of starting the food literacy education in primary school and continuing it throughout the secondary and senior secondary years. The development of a national food literacy education framework similar to the ‘British framework of skills and knowledge around food, diet, and physical activity for children and young people aged 5 to 16 years’  would heFuture research should examine the opinions of different stakeholder groups, especially those of under-researched groups such as curriculum leaders, bureaucrats, media, food activists groups, etc., regarding the strengths, weaknesses, opportunities, and threats facing secondary school food literacy education in Australia (or elsewhere). These findings would identify the stances of different levels of society regarding this form of education. This could initiate a broad public discussion regarding the importance of school food literacy education and help raise its status and profile in education and the broader society.This study had several strengths. First, it included food, health, and education professionals from 15 different countries . This provides international insights into the importance of, and challenges encountered by, senior secondary school food literacy education. Second, it explored a broad range of food, health, and education professionals’ opinions of senior secondary school food literacy education. According to the best of the authors’ knowledge, this study is unique and no previous surveys have explored international food, health, and education professionals’ opinions of the aspects of food literacy education explored in the present survey. This survey was open to both Australian and overseas professionals with the aim of obtaining international food, health, and education professionals’ perspectives of senior secondary school food literacy education. However, the majority of respondents were from Australia (69%). Thus, the findings may mainly depict Australians’ views of school food literacy education. The third strength was the inclusion of both quantitative and qualitative questions in the questionnaire  ,44. ThisOne of the limitations of this study was its relatively low sample size and the relatively low survey completion rate. Out of the 282 professionals who commenced the survey, only 55% completed it. The professionals’ demanding workloads may have prevented them from completing the survey at once and consequently resulted in them forgetting to complete it later. A reminder email may have helped to increase the completion rate. However, it was not possible to send such an email, as respondents’ contact details were not known and most of the respondents were invited to complete the survey via indirect methods (as mentioned earlier). For the same reason it was not possible to determine the overall response rate of the survey . The sample was comprised mainly of females (81%). Therefore, caution should be applied when interpreting the results, as the overall food-related professionals’ opinions of school food literacy education might be different to those of the study respondents.This study highlights the importance of senior secondary school food literacy education and provides some useful suggestions for its improvement from the viewpoint of food, health, and education professionals. These findings add to ongoing discussions of ways to strengthen school food literacy education and emphasise the value of involving these professionals in such efforts.


To evaluate the feasibility of quantitative analysis of chest computed tomography (CT) scans for the assessment of lymph node (LN) involvement in patients with pulmonary tuberculosis and sarcoidosis.In 47 patients with tuberculosis (n = 26) or sarcoidosis (n = 21), 115 lymph nodes  were visually analyzed on chest CT scans according to their size, location, attenuation and shape. Each node was manually segmented using image analysis tool, which was quantitatively analyzed using the following variables: Feret’s diameter, perimeter, area, circularity, mean grey value (Mean), standard deviation (SD) of grey value, minimum grey value (Min), maximum grey value (Max), median grey value (Median), skewness, kurtosis, and net enhancement. We statistically analyzed the visual and quantitative CT features of tuberculous and sarcoid LNs.In visual CT analysis, the mean node size in sarcoidosis was significantly greater than that in tuberculosis. There were no statistical differences between tuberculous and sarcoid LNs in terms of location and shape. Central low attenuation and peripheral rim enhancement were more frequently observed in tuberculous LNs than in the sarcoid ones. In quantitative CT analysis, there were significant differences in the values of the Feret’s diameter, perimeter, area, circularity, mean grey value, SD, median, skewness, and kurtosis between tuberculous and sarcoid LNs.Quantitative CT analysis using CT parameters with pixel-by-pixel measurements can help to differentiate of tuberculous and sarcoid LNs. Granulomatous lymphadenitis can be classified into infectious and non-infectious types. A typical example of infectious granulomatous lymphadenitis is tuberculous lymphadenitis and that of non-infectious lymphadenitis is sarcoidosis . TubercuIn particular, tuberculosis affects the right paratracheal or hilar lymph nodes, most frequently in the thoracic region. Tuberculous lymphadenitis is characterized as presenting low attenuation as well as peripheral rim enhancement on computed tomography (CT) images. Pathologically, central low attenuation indicates caseous necrosis, while peripheral rim enhancement indicates granulation tissue accompanying inflammation and hypervascularity . In patiMost studies have investigated the involvement of mediastinal or hilar lymph nodes in tuberculosis or sarcoidosis by visual analysis of CT images. However, the efficacy of visual analysis in distinguishing tuberculous lymphadenitis and sarcoidosis might be limited in cases of tuberculous lymphadenitis without central low attenuation and peripheral rim enhancement.In order to overcome the limitations of conventional visual analyses, a quantitative CT analysis method has been introduced, which allows the quantification and analysis of the differences in grey-scale images that might not be recognized by human eyes, using computer software. Many previous studies have applied quantitative CT analysis for the evaluation of lymph node involvement in various diseases , 5. BayaThe institutional review board of our institution approved this retrospective study (C2016062 (1805)) and waived the requirement for informed patient consent for inclusion in this study.A search of our institutional electronic medical records database yielded the data of 580 patients with either thoracic tuberculosis (n = 521) or sarcoidosis (n = 59). Patients with tuberculosis had been diagnosed between January 2009 and January 2014 by polymerase chain reaction analysis, bacterial culture, or biopsy, while those with sarcoidosis had been diagnosed between April 2006 and January 2015 by pathological analysis by thoracic lymph node or lung biopsy. Of the 580 patients, 414 with either thoracic tuberculosis (n = 393) or sarcoidosis (n = 21) who had undergone contrast-enhanced chest CT  were initially selected. Of the 414 patients, those presenting either mediastinal lymph nodes with short-axis diameter > 1 cm or hilar lymph nodes with short or long-axis diameters > 1 cm were selected. Thus, finally, 47 patients with tuberculosis (n = 26) or sarcoidosis (n = 21) were included in this study.A total of 115 lymph nodes  in the CT images of the 47 patients were visually analyzed in terms of their size, location, attenuation, and shape. The sizes of the hilar and mediastinal lymph nodes were evaluated by measurement of the longest diameter along any of the axes and the short axis, respectively, using the Picture Archiving and Communication System . The locations of the lymph nodes were classified into 14 regions, and the lymph nodes were then categorized based on location into four groups—the superior mediastinal , inferior mediastinal , aortic (subaortic and para-aortic), and hilar lymph nodes—according to the lymph node map of the International Association for the Study of Lung Cancer (IASLC) [The CT images of the 115 lymph nodes were converted into digital imaging and communication in medicine (DICOM) files and transferred to image analysis tool  .The targFeret’s diameter (Feret’s): The longest distance between any two points along the selection boundary; also known as the maximum caliperPerimeter: Length of the outside boundary of the selectionArea: Area of the selection in square pixelsCircularity: Mean grey value (Mean): Average grey value within the selectionStandard deviation (SD): Standard deviation of the grey values used to calculate the mean grey valueMinimum grey value (Min): Minimum grey value within the selectionMaximum grey value (Max): Maximum grey value within the selectionMedian: Median value of the pixels in the image or selectionSkewness: Third order moment about the meanKurtosis: Fourth order moment about the meanNet enhancement value: Mean grey value of a contrast-enhanced image minus the mean grey value of a non-contrast enhanced imageAll of the tuberculous and sarcoid lymph nodes were sub-classified according to presence or absence of lung involvement on the basis of both visual and quantitative CT image analyses by blinded method without clinical information.We statistically analyzed the visual and quantitative CT features of the tuberculous and sarcoid lymph nodes using the Mann-Whitney test and the Student’s t-test, chi-square test, or Fisher’s exact test. Statistical analysis was performed using PASW Statistics for Windows, Version 18.0 . A p value < 0.05 was considered statistically significant.The results of quantitative CT image analysis of the tuberculous and sarcoid lymph nodes are presented in The results of quantitative CT image analysis of lymph nodes without central low attenuation are summarized in The results of quantitative CT image analysis of lymph nodes with central low attenuation are summarized in To date, most studies have evaluated lymph nodes by means of visual assessment of their size and shape on CT scans. For instance, loss of normal oval shape, increase in short-axis diameter, unclear boundaries, and presence of central low attenuation were often used as indicators for the diagnosis as well as differentiation of lymph node diseases. However, visual CT image analysis on the basis of shape and size of lymph nodes exhibits significant limitations in the diagnosis of lymph node metastasis as well as infectious and inflammatory lymph node diseases. In order to overcome these limitations, FDG PET/CT, a technique that can assess cellular metabolic activity, was introduced. However, the superiority of this technique over visual CT image analysis in terms of specificity is debated. In addition, several studies evaluated the efficacies of quantitative analyses of CT and ultrasonography (US) images in the differentiation of metastatic and benign lymph node diseases , 9, 10. In a comparative study of the average size of lymph nodes on CT images between tuberculosis and sarcoidosis, Dhooria et al. reported no significant differences in the short-axis diameters of lymph nodes between the two diseases . In contComputer-based quantitative analysis of CT images, which can be used to assess minimal changes in pixel units that might not be recognized by human eyes, has quickly emerged as a feasible diagnostic tool. In the present study, there were statistically significant differences in the skewness and kurtosis of the CT profile histograms between the tuberculosis and sarcoidosis groups .The CT pIn cases with no central low attenuation, it is difficult to differentiate between tuberculous and sarcoid lymph nodes by visual CT image analysis. However, in the present study, the results of quantitative CT image analysis of lymph nodes with no central low attenuation revealed statistically significant differences in the Feret’s diameter, perimeter, area, and circularity of lymph nodes between tuberculosis and sarcoidosis. Therefore, despite their limitations in the accurate evaluation of pathological and clinical significances, we believe that these quantitative variables could be potentially used for the differentiation of tuberculosis and sarcoidosis.There are several limitations of our study. First, there is a possibility of selection bias because of the retrospective nature of our study as well as the small sample size. Consequently, imaging data, such as the scanning parameters for chest CT image acquisition , were not homogenous. Second, not all of the lymph nodes were pathologically evaluated in order to confirm the diagnosis of tuberculosis or sarcoidosis. Although pathological lymph nodes were selected for inclusion in our study on the basis of their size, the possibility of lymph node enlargement unrelated to either tuberculosis or sarcoidosis was not considered. Third, the lymph nodes were manually segmented using a touch pen. Although the accuracy of segmentation was finally confirmed by a thoracic radiologist with 10 years of experience in thoracic imaging, there is a possibility of measurement error. In the future, semi or fully automated segmentation using image analysis software with much improved algorithms might prove feasible for quantitative CT image analysis of lymph nodes. Finally, we did not include the performance test of the quantitative CT image analysis, with sensitivity, specificity and accuracy in the differentiation between the two granulomatous diseases. However, this quantitative CT analysis is likely to be useful in the evaluation of visually normal lymph nodes and is expected in future studies.In conclusion, we investigated the feasibility of various CT quantification parameters for the differentiation of tuberculous and sarcoid lymph nodes. To our knowledge, the present study was the first to perform quantitative analysis of imaging data extracted from the CT images of mediastinal and hilar lymph nodes in pulmonary tuberculosis and sarcoidosis, using image analysis software. We believe that quantitative CT image analysis for the measurement of fine pixel units, which might not be recognized by human eyes, can help identify CT quantification parameters for the differentiation of tuberculous and sarcoid lymph nodes.


Bacillus thuringiensis (Bt) crops is pursued worldwide in a variety of forms and to varying degrees of success depending on context. We examine this context using a comparative socioecological analysis of resistance management in Australia, Brazil, India, and the United States. We find that a shared understanding of resistance risks among government regulators, growers, and other actors is critical for effective governance. Furthermore, monitoring of grower compliance with resistance management requirements, surveillance of resistance, and mechanisms to support rapid implementation of remedial actions are essential to achieve desirable outcomes. Mandated resistance management measures, strong coordination between actors, and direct linkages between the group that appraises resistance risks and growers also appear to enhance prospects for effective governance. Our analysis highlights factors that could improve current governance systems and inform other initiatives to conserve susceptibility as a contribution to the cause of public good.Cooperative management of pest susceptibility to transgenic The online version of this article (10.1007/s13280-019-01167-0) contains supplementary material, which is available to authorized users. Bacillus thuringiensis (Bt) crops, using a socioecological system approach to highlight the diversity of contexts in which biocide susceptibility problems and the design of contextually explicit solutions emerge.Pesticides and antimicrobials enhance food security and human health by controlling pests and pathogens, but can also contribute to increased vulnerability by reducing the diversity of control methods and increasing dependence on new technologies. Complementary alternatives for managing the evolution of resistance in targeted organisms are underdeveloped and fraught with challenges  in which the private benefits of using Bt crops contribute to overuse of the resource . In the following sections, we refer to insecticide resistance management (IRM) as the use of refuges and other IPM tactics to manage resistance evolution to Bt crops.Planting refuges of non-Bt crops has been the prominent tactic to delay resistance evolution to Bt crops, although adoption of other IPM measures such as crop rotation is required in some contexts , which were the first commercialized. Refuges are also needed to delay resistance to pyramided Bt crops, which produce two or more toxins  targeting the same pest and are more effective than single-toxin crops for delaying resistance  pest biology and ecology, (2) genetic factors, and (3) characteristics of Bt crops and agricultural landscapes.Helicoverpa armigera . For example, refuges of non-Bt cotton were discontinued in most of the USA Cotton Belt when studies indicated that non-cotton plants provide many wild-type moths of the key target pests in Bt cotton fields of these regions EPA . SimilarThe several genetic factors affecting the evolution of resistance are listed in Table Helicoverpa zea exploits several types of Bt corn and cotton, and in the Cerrado region of Brazil where the fall armyworm and Helicoverpa spp. feed on several types of Bt corn, cotton, and soybean (Appendix S2). By contrast, only one type of Bt crop (cotton) is used in Australia (Appendix S1).The presence of similar Bt toxins in different host crop types can increase refuge needs for polyphagous pests because such crops select for resistance concurrently instead of independently . Similarly, the IRM value of a pyramided crop is reduced when it is introduced after evolution of pest resistance to a related single-toxin crop  .The most direct outcome for evaluating Bt resistance management is the level of resistance in target pest populations . This objective involves considering the current and future benefits of the technology relative to alternative economic investments. For example, increasing refuge areas may reduce current yields. Strategic alternatives would thus use the proceeds resulting from not increasing refuge areas to deploy alternative pest control tactics to sustain yields . In some cases, public research and extension services have built trust with growers through long-term relationships, helping to support planting of refuges  assesses the risks of the technology to human and environmental health and safety and issues plans to mitigate them, which may include licensing conditions for the registrant . To ensure appropriate resistance management, the Australian Pesticides and Veterinary Medicines Authority (APVMA) then works with the registrant and an industry expert committee . A peak industry body  facilitates TIMS’s work. The APVMA seeks endorsement from TIMS on required plans and considers variations submitted by the registrant. Growers sign contracts with the registrant, which mandate adherence to the plan. The registrant is responsible for auditing planting dates, refuges, and end of season destruction of pest populations, and reports compliance to TIMS and the APVMA. The registrant reserves the right to prevent future use of their product by growers who do not comply.Before registration, OGTR considers information from the registrant regarding (1) biology of the parent organism, 2) method and nature of the genetic modification and effect of introduced genes, (3) characteristics of the receiving environment, and (4) relevant Australian and international approvals. Post-registration, the registrant is responsible for working with TIMS to annually provide evidence to APVMA that resistance is being effectively managed including (1) user awareness of, and compliance with the Resistance Management Plan  works with Cotton Australia to identify research needs, requests research proposals from academic and government agency researchers, and undertakes commissioning projects directly with experts. This research is partly funded by a mandatory levy imposed on growers that is matched by the Australian Government. The registrant generally does not contribute funds to the industry investments but often collaborates by running parallel programs.A dedicated extension team supported jointly by Cotton Australia, Cotton RDC and the national cotton seed distribution company (CSD) interacts with researchers to develop and promote resistance management strategies to growers and private consultants. The registrant also works extensively with stakeholders to promote implementation of IRM.The National Technical Biosafety Commission (CTNBio) assesses biosafety of genetically modified organisms for human, animal, and environmental health CTNBio, . CTNBio S. frugiperda, and problems caused by the recently detected H. armigera have resulted in severe economic losses to Bt and other crops (Appendix S2). To address these acute problems, growers, grower associations, and private consultants in the Cerrado region formed a group to initiate IRM in consultation with industry and researchers. This initiative, formalized in 2014 by the Ministry of Agriculture as the Technical-Scientific Group for Resistance Management (GTMR), produced few tangible results. IRAC Brazil and IRAC International, which are technical groups responsible for providing a coordinated industry response to resistance problems, later outlined recommendations for management of resistance to insecticides and Bt crops in Brazil (IRAC http://www.in.gov.br/materia/-/asset_publisher/Kujrw0TZC2Mb/content/id/56640378).Resistance to Bt crops in fall armyworm, zil IRAC . Althougzil IRAC , the extzil IRAC . At the http://www.envfor.nic.in/divisions/csurv/geac/bgnote.pdf). For registration of Bt cotton, registrants must provide data on (1) agronomic performance and nontarget effects of Bt crops, (2) pest biology and baseline susceptibility to Bt toxins in key target pests, and (3) IRM strategies for the key target pests .The Genetic Engineering Appraisal Committee (GEAC) under the auspices of the Ministry of Environment, Forests and Climate Change is responsible for registration of Bt crops (ts Ghosh . Registrhttp://www.moef.gov.in/sites/default/files/geac/bgnote.pdf). To promote refuge planting, approved seed companies supply non-Bt cotton or pigeon pea seed with purchased Bt seeds, , a campaign to educate growers about IRM and IPM practices was undertaken (ISAA http://seednet.gov.in/SeedGO/2016/173355_2016.pdf).Many stakeholders work together to promote implementation of IRM. However, implementation of IRM is challenged by many factors, including a large number of resource-poor growers planting Bt cotton (> 7.2 million), regional diversity, inadequate education, and infrastructure, and unpredictable returns. Furthermore, implementation of IRM differs across states because agriculture is under state jurisdiction, and this has caused problems with use of unauthorized Bt cotton seeds Section “”. In resken ISAA . Since 2EPA mandates resistance management strategies by stipulating requirements to be met by registrants before and after registration. Product registrations are generally time-limited and conditional on registrants meeting these requirements  the biology and ecology of target pests, (2) susceptibility of target pests to Bt toxin(s), (3) the mode of action of toxins, inheritance of resistance, and potential for cross-resistance, and (4) resistance management strategies for key target pests. Post-registration requirements include: (1) educating growers about resistance management, (2) monitoring grower compliance with IRM requirements, (3) monitoring changes in resistance to Bt toxins in target pests, and (4) developing and implementing remedial action plans to address cases of practical resistance. Registrants provide annual reports on post-registration conditions to EPA  or industry-led associations  mandate conditions for registering Bt crops. Brazil’s voluntary use of IRM contrasts with other cases. Standard open-access resource theory and experience with voluntary IRM for herbicide resistant crops in the USA NRC  predict In contrast to India, conditions for registration of Bt crops in Australia and the USA include auditing compliance with IRM requirements. In India, low grower compliance with refuge mandates has facilitated rapid evolution of resistance to Bt cotton in pink bollworm. These differences indicate that compliance monitoring is an essential component of IRM programs. However, effective audits are difficult, given the large number of cotton growers in India. In hindsight, a more robust approach for IRM in this situation could have been to release a seed mixture of pyramided Bt cotton and non-Bt cotton from the start Section “”. HoweveAssessment of the risk of resistance for Bt crops is inherently uncertain because of the multiple biological and socioeconomic drivers discussed above. Accordingly, effective society–biology loops are required to adjust IRM strategies and implement remedial actions when needed Section “”. In botS1), an association of cotton growers advised by a broad coalition of stakeholders was granted autonomy by government authorities to oversee resistance management issues. This grower-centric approach likely facilitates implementation of IRM and remedial actions, compared to the regime in the USA where the lack of direct ties between EPA and growers results in an indirect enforcement system under the responsibility of technology providers. Nevertheless, even with significant investments in stewardship, there is no guarantee of successful outcomes, as shown in the USA where growers in many regions exhibit poor compliance that has led to resistance problems .Policy incentives are also relevant to participants in research and extension. For research, funding is the most obvious carrot. However, a complementary stick in some contexts could be to require a stewardship component in research proposals related to pest control and crop protection. For extension, incentives could include using enrolment of growers in IRM programs as a performance metric in promotion. For research and extension, other valuable incentives could encourage service on panels overseeing stewardship for Bt crops  sensitization of growers to resistance risks, (2) monitoring of grower compliance with IRM requirements, (3) monitoring of increases in resistance, and (4) implementation of remedial actions, ideally before practical resistance occurs. The comparison between Australia’s governance system and other countries also indicates that strong, direct linkages between the group that appraises resistance risks and growers appear to facilitate adoption of IRM. Nevertheless, in some cases, adoption of IRM remains inadequate even with elaborate investments in governance systems, indicating a need for further context-dependent private and public incentives for participants.We have shown that Australia and the USA maintain sophisticated governance systems enforcing the four safety net activities mentioned above, unlike India where the large number of growers hinders monitoring of grower compliance with IRM requirements. In countries where socioeconomic conditions impede stewardship, it is therefore relevant to consider robust resistance management strategies that alleviate the need for grower compliance. Based on our review of the Indian system and recent events in China Section “”, we proSupplementary material 1 (PDF 637 kb)Below is the link to the electronic supplementary material.


In the 10 hospitals studied, we found that hospital policies, protocols, and interventions only partially align with WHO early newborn care recommendations, and that many hospitals still use outdated and non-medically sound practices. In the 10 hospitals studied, we found that hospital policies, protocols, and interventions only partially align with WHO early newborn care recommendations, and that many hospitals still use outdated and non-medically sound practices. As a part of the process of implementing Early Essential Newborn Care (EENC) in China, which are evidence-based interventions recommended by the World Health Organization (WHO), we sought to understand whether current hospital policies are consistent with WHO-recommended standards and what factors influence their use. Data from the study will help inform policy changes needed to support the introduction of evidence-based childbirth and early newborn care practices effectively and to inform further scale up of EENC nationwide.Ten randomly selected hospitals in 4 early-introducing provinces participated in the study. We collected data from 20 simulated delivery scenario observations and focus group discussions and individual interviews with 10 hospital management staff. Policies, protocols, and guidelines related to childbirth and newborn care practice were also collected and reviewed at each hospital. Additionally, a survey was emailed to 15 childbirth and newborn experts from the 4 selected provinces and completed by 13. Data were compared with WHO EENC evidence-based standards to calculate the agreement rates. Barriers to introducing evidence-based guidelines were identified in focus groups and key informant interviews, then combined into common categories.Hospital policies were not consistent with WHO recommendations in 10 (59%) of the 17 delivery and early newborn care practices. Delayed cord clamping was recommended by 30% of hospital protocols and prolonged skin-to-skin contact by 13%, neither of which were observed in the delivery simulations. Kangaroo mother care (KMC) for stable preterm babies was required in only 17% of the hospitals; no preterm babies had KMC initiated, with all immediately separated from their mothers and admitted to neonatal intensive care units. Newborn resuscitation equipment was required to be placed within 2 meters of the delivery bed in 84% of hospital protocols, but was prepared in only 40% of cases. Immediate drying after birth was required in 48% of hospital protocols, but was initiated in only 20% of observed cases.Current childbirth and early newborn care policy and practice in China is not aligned with WHO recommendations for some major interventions. To make it easier and safer for hospital workers to practice EENC, expert working groups and national policies must be established to address inconsistencies and cultural beliefs and provide a strong, evidence-based set of guidelines for hospitals and health workers to follow. With an estimated 16 million babies born annually, China has achieved remarkable progress reducing deaths among children under 5 over the past 2 decades. Between 1991 and 2015, the under-5 mortality rate of Chinese children declined by 80% from 79.2 to 10.7 per 1,000 live births and infant mortality declined from 50.2 to 8.1 per 1,000 live births.,Law of the People's Republic of China on Maternal and Infant Health CareMeasures for the Implementation of Law of the People's Republic of China on Maternal and Infant Health CareNational Program of Action Plan for Women Development in China (2011–2020)National Program of Action Plan for Children Development in China (2011–2020)7—that identify 10-year objectives, main indicators to measure and meet, and strategies for improving women's and children's health, education, protection, and rights. While these documents covered a wide range of issues, quality early essential newborn care (EENC) was not mentioned.Since the World Summit for Children in 1990, China has invested in strengthening policy and legislation for improving the child health systemAction Plan for Healthy Newborn Infants in the Western Pacific Region (2014–2020).Early Essential Newborn Care Clinical Practice Pocket Guide,Progress on improving the quality of care around delivery and in the early newborn period has been slower than other aspects of child health and recognized as an area that needs renewed attention.To improve quality of care during delivery and in the newborn period, 8 countries collaborated with WHO/WPRO to develop a regional action plan to implement and scale up EENC interventions.In 2015, the National Health and Family Planning Commission (NHFPC) in China began prioritizing the introduction of EENC, beginning with improving quality of hospital care in 4 early-implementation provinces. Preliminary discussions with senior hospital staff found that hospital newborn health protocols often vary considerably within and across facilities. Prior to the implementation of EENC in China, we sought to first understand what protocols were being used in hospitals in the 4 early-implementation provinces, whether current policies were consistent with WHO-recommended standards, and what factors influence their use. The aim of these data was to inform the policy changes needed to support the introduction of evidence-based delivery and early newborn care practices effectively and to inform scale up to other regions of the country.We conducted the study between December 2015 and April 2016 using observations of simulated deliveries, focus group discussions with the simulation participants, individual interviews with hospital management staff, a key informant survey mailed to Neonatal Resuscitation Program (NRP) instructors, and a desk review of hospital protocols.The study was conducted in Beijing, Shaanxi, Sichuan, and Inner Mongolia provinces. The NHFPC chose these 4 provinces because they are representative of provinces with different economic development statuses. In each province, 1 city and 1 county within this city were randomly selected. At each level—provincial, city, and county—1 hospital was randomly selected, for a total of 10 selected hospitals. Since Beijing is a municipality directly under the central government, only city- and county-level hospitals were selected.We conducted 2 simulated deliveries in each of the 10 hospitals selected, for a total of 20 simulated deliveries, and health care provider focus groups and interviews to assess current practices. We used scenario assessments instead of actual deliveries for 2 reasons: (1) we could not get permission from pregnant women to observe their actual deliveries, and (2) we believed that using simulated cases would be an easier and less stressful way for health care providers to demonstrate their routine practices.Simulated delivery scenarios, followed by focus group discussions, were used to assess current hospital and health worker practices without jeopardizing the health and safety of delivering mothers and their newborns.,Six staff members—2 midwives, 2 obstetricians, and 2 pediatricians—were selected randomly in each hospital to join a delivery simulation session and a focus group discussion. The sessions were conducted in a delivery room, or a room set up like a delivery room, and had 2 components. First, the facilitator asked a midwife and an obstetrician to demonstrate management of a routine normal delivery—dividing tasks according to the routine protocol—using a manikin infant, delivery kits, and other delivery room supplies. The facilitator observed and scored the tasks performed using a standard EENC skills review method and checklist, with 1 participant playing the role of the mother and the others conducting the delivery.In addition to the simulated delivery observations and the focus group discussions, 1 hospital management staff at each hospital was interviewed (N=10) about how the implementation of delivery and early newborn care policies was conducted, including how the hospital monitored adherence to hospital protocols and what was done if protocols were not followed. All observations, focus group discussions, and individual interviews were recorded for data management and analysis.A survey was emailed to 15 national NRP instructors in the 4 provinces to collect data on delivery and early newborn care policies, protocols, and guidelines. The group of NRP instructors included national and provincial health bureau managers, MCH program officers, and childbirth and newborn care specialists. A survey questionnaire was developed and distributed via email; respondents were asked to return the completed survey via email. The questionnaire asked respondents to compare WHO recommendations on key practices to current childbirth and newborn care practices, policies, and recommendations; describe how adherence to protocols within hospitals is monitored; and identify perceived barriers and challenges to implementing WHO-recommended guidelines.At each of the hospitals, current policies, protocols, and guidelines related to childbirth and newborn care practice were also collected and reviewed. The documents reviewed included both practice guidelines  and management procedures . If protocols referred to primary sources, such as medical society recommendations, textbooks, or adapted international guidelines, these were also reviewed.Data on the policies, protocols, and guidelines were extracted and entered into a Microsoft Office Excel 2013 file that allowed comparisons with WHO EENC evidence-based standards. Agreement rates for each practice or intervention were calculated by dividing the number of hospitals with protocols consistent with WHO recommendations by total number of hospitals. Each health care provider focus group discussion and interview was transcribed into a Microsoft Word 2013 file. Focus group and interview notes and transcripts were reviewed to summarize and compare the hospital protocols with WHO recommendations. Findings on accreditation mechanisms for current hospital protocols and perceived barriers to change current protocols were summarized across all hospitals and combined into common categories.Institutional ethics approval to conduct the study was obtained from the institutional review board at the National Center for Women and Children's Health at the Chinese Center for Disease Control and Prevention (NCWCH). Informed consent was obtained from all health care providers participating in observations and interviews.Ten hospitals from 4 provinces were sampled. Site visits with desk review of policies, focus group discussions, individual interviews, and delivery observations were conducted at those hospitals. Thirteen of 15 mail survey questionnaires were returned. Respondents included 5 pediatricians, 3 obstetricians, 3 midwives, and 2 MCH program officers.The number of annual deliveries and the number and type of staff available to provide delivery services varied greatly between hospitals . In 9 ofA review of hospital protocols—by self-report through the survey and onsite review by study staff—revealed that hospital protocols were consistent with WHO guidelines for 7 (41%) of the 17 delivery and early newborn care practices, including routine use of the partograph, use of corticosteroids for women of 24 to 34 weeks' gestation at risk of preterm birth, optimal timing technique for cord cutting, use of oxytocin for active management of the third stage of labor, routine administration of hepatitis B and bacillus Calmette-Guérin vaccines, and delayed bathing until at least 24 hours after birth . DespiteHospital protocols and observed practices were consistent with only 41% of the 17 WHO-recommended delivery and early newborn care practices.The practices of hospital staff who were observed in routine delivery scenarios were consistent with WHO recommendations in the same 7 practices areas noted for hospital protocols . The othSeveral potential barriers to introducing evidence-based guidelines were identified in focus group discussions with simulation participants and key informant interviews with NRP instructors. The results are summarized below.Key barriers to improving hospital protocols included the lack of a standardized evidence-based set of clinical protocols and guidelines, supported by peer-reviewed literature and aligned with a system of evaluation.Guide for Prevention and Treatment of Postpartum HemorrhageEach province has developed an MCH plan and the measures for administration of midwifery techniques guidelines. These provincial policies regulate the certification of delivery services, required preservice and in-service trainings and qualifications for providers, accreditation mechanisms and regulations, basic equipment and facility requirements, and content of services for the different levels of hospitals. However, none of these guidelines provide detailed clinical practice standards or protocols on immediate childbirth and early newborn care, leaving hospitals to look to other resources. For example, the While national- and provincial-level MCH service evaluation standards are currently available, they only focus on basic principles and requirements, not core evidence-based practices. Hospitals are evaluated every 3 or 4 years by provincial authorities. If the basic standards are not met, the hospital may be prohibited from providing MCH services the following year. If an individual staff member is found not to be practicing protocols, he or she may be disciplined by verbal criticism, deduction of wages, suspension of license, or a lawsuit, depending on the severity. Most hospital staff believe they should follow domestic textbook recommendations and Medical Society guidelines because these are officially sanctioned, and have legal status in case of medical disputes.Peer-reviewed journal articles used for WHO GRADE recommendations, for example, are felt to be important to explain key practice steps such as prolonged skin-to-skin contact, delayed cord clamping, non-use of suction except for non-breathing babies born with meconium staining and dry cord care. This is particularly important for explaining why new evidence-based recommendations are different from those used previously. For example, the previous duration for skin-to-skin contact recommended in baby-friendly hospital guidelines was 30 minutes, not 90 minutes. Similarly, many staff believed that applying disinfectants and covering the cord stump is important to prevent sepsis, and would like to see relevant data on this issue. In two hospitals, staff were concerned that mothers may not be able to safely hold babies in skin-to-skin contact and may drop them; in some cases there was concern that this position may be associated with an increase in the risk of asphyxia.A number of cultural practices and beliefs held by families, particularly grandparents, prevent evidence-based practices from being applied including early separation of the newborn from the mother so the newborn can be shown to other family members, concerns that skin-to-skin contact with the mother is dangerous, a desire to bathe the newborn early, and beliefs that keeping the cord stump uncovered will allow “cool breezes” to pass through the cord stump into the newborn's body and cause illness.Maintaining skin-to-skin contact for 90 minutes, or until the first breastfeeding, usually requires the assistance of postnatal care staff who may not be familiar with the how and when to initiate each technique and for how long. Breastfeeding counseling, in particular, is essential for initiating the first feed. In some cases, staff members were concerned that beginning new practices would increase the workload for midwives or nursing staff and wanted clarification on how responsibilities would change.Our findings suggest that although China has no national EENC guidelines, many childbirth and newborn health care protocols and practices were evident in various documents at the hospital level. However, technical protocols related to childbirth and newborn health care were fragmented, outdated, and developed through a non-scientific guideline development process, and over half were not consistent with WHO guidelines. Because the EENC recommendations are new and not included in current protocols, facilities were not expected to adhere to them. To introduce EENC in China, implementers must recognize the need to identify necessary support for and changes in hospital policy, organization, accreditation mechanisms, and cultural beliefs.Many of the technical childbirth and newborn health care protocols used by the hospitals studied were limited, outdated, and did not use a strict evidence-based guideline development process.Healthy Child Action Plan (2018–2020),Since 2013, the Chinese NHFPC has been working with the United Nations Children's Fund (UNICEF) China to develop a newborn survival framework and service package, as the government response to the WHO and UNICEF Every Newborn Action Plan. The central and provincial health authorities have developed various policy documents that, for example, regulate the certification of delivery service, required preservice and in-service trainings and qualifications for providers, accreditation mechanisms and regulations, requirements for basic equipment and facilities, and a description of services for different levels of hospitals. In May 2018, the NHPFC issued the In 1988, less than half of all women in China gave birth in hospital; within 20 years, hospital births became almost universal.Despite of these proven effective interventions, many inappropriate interventions are still practiced in hospitals that interfere with the baby's ability to adapt and feed well, such as unnecessary suctioning, immediate cord clamping, and delayed drying. These outdated practices increase the risk of delayed fetal-to-newborn circulatory adjustments, infection, breathing problems, hypothermia, anemia, acidosis, coagulation defects, brain hemorrhage, and trauma.One recently published UNICEF reviews identified problems and bottlenecks in the health system to provide newborn care.The development and adoption of national evidence-based guidelines must be initiated and approved at the national level before being implemented in hospitals and incorporated into an effective accreditation mechanism.Neonatal deaths in the Western Pacific Region declined slowly between 1990 and 2015.China has been working closely with various partners to prioritize newborn health by developing a national action plan and technical guideline that aligns with WHO recommendations. However, at the moment, hospital policies, protocols, and interventions only partially align with WHO recommendations. To make EENC easier and safer for hospital workers to practice, expert working groups and national policies must be established to address inconsistencies and cultural beliefs and provide a strong, evidence-based set of guidelines for hospitals and health workers to follow.


Older adults with disabilities face a higher risk of experiencing poor health and social isolation in later life. Prior research has shown that social factors such as supportive relationships can modify disablement trajectories and reduce the likelihood of negative outcomes. Although research has considered the functional benefits of relationships through examining mechanisms like social support provision, the effects of network structure on the disablement process are not well understood. This study examines multiple social network mechanisms to explain the link between disability, health, and social participation among older adults. We ask, do social networks characteristics mediate or moderate the effects of increasing functional impairment on health and social participation? We analyze longitudinal panel data from the National Social Life, Health, and Aging Project 2005 & 2010, including 2,261 adults aged 57-85. Respondents named 9,587 network members in 2005. We model indicators of health and social participation at 5-year follow-up using trajectories of functional impairment and social network characteristics. We find that larger, denser, and more supportive networks are associated with better health and more frequent social activity at follow-up. Furthermore, social network structure mediates the relationship between increasing functional impairment and health, but moderates the effect of impairment on social participation. For example, participants with more dense networks are more likely to maintain high social activity at follow-up, even at relatively high levels of impairment. This study demonstrates that functional impairments are not inherently disabling. Instead, personal and social resources can reduce the potential burdens of impairment in individuals’ lives.


While typhoid fever remains an important cause of illness in many low- and middle-income countries, important insights can be learned by exploring the historical experience with typhoid fever in industrialized countries. We used archival research to examine British and American attempts to control typhoid via sanitary interventions from the 1840s to 1940s. First, we assess how varying perceptions of typhoid and conflicts of interest led to a nonlinear evolution of control attempts in Oxford, United Kingdom. Our qualitative analysis shows how professional rivalries and tensions between Oxford’s university and citizens (“gown and town”), as well as competing theories of typhoid proliferation stalled sanitary reform until the provision of cheap external credit created cross-party alliances at the municipal level. Second, we use historical mortality data to evaluate and quantify the impact of individual sanitary measures on typhoid transmission in major US cities. Together a historiographic and epidemiological study of past interventions provides insights for the planning of future sanitary programs. Salmonella Typhi’s isolation and proof of pathogenicity  [Popular accounts of Western typhoid control often follow heroic narratives of a “great sanitary awakening”  with a dy, 1884) , the devy, 1884) .Salmonella enterica serovar Typhi taxonomies remained contested until the 1930s. Despite typhoid fever’s prominence in contemporary discourse and statistics, extrapolating disease incidence from historical sources is thus ridden with difficulties. There was also no inevitable correlation between growing awareness of typhoid and the implementation of effective sanitary control strategies. Meanwhile, historians continue to disagree on sanitary interventions’ relative impact on typhoid mortality in relation to other factors such as improved healthcare and nutrition [Progress was supposedly inevitable once “rational” practitioners had discovered typhoid’s microbial cause and debunked competing theories. While we do not discount the role of the contemporary discovery of typhoid’s waterborne transmission and bacterial causation, historians have shown that narratives of a resulting linear evolution of successful science-informed control measures are inaccurate: Clinical definitions of typhoid remained in flux for most of the 19th century; pathologies were not routinely conducted and did not always provide clear results; the bacteriological revolution filtered unevenly through society; serological diagnosis remained error-prone; and utrition .Here, we reevaluate the history of typhoid control in Britain and the United States between the 1840s and 1940s. During this period, both countries undertook significant sanitary interventions to control enteric infection. Using historical and epidemiological methodologies, we examine different interventions’ origins and impacts. First, we examine the hit-and-miss evolution of 19th-century sanitary interventions. The city of Oxford (United Kingdom) is exemplary of the impact of changing central government powers alongside changing concepts of typhoid transmission and causation. Second, we examine the various approaches to improving water and sanitation infrastructure across different representative cities in the United States around 1900. Our analysis highlights how the availability of cheap municipal credit played an important role in bringing together important actors to fund the infrastructure development necessary for typhoid control.Oxford’s environmental context, mixed urban-rural structure, rapid expansion, and pronounced social tensions make it a useful case study that can also provide insights for current typhoid control strategies in rapidly urbanising contexts. Historically, Oxford shared many of the socioenvironmental features exhibited by present-day typhoid-endemic settings. Environmentally, the city’s low-lying location at the confluence of 2 rivers and porous soil structure provided conditions for typhoid proliferation as a result of flooding and the contamination of drinking water wells with human waste . StructuAccording to contemporaries, sanitary conditions in early 19th-century Oxford were dire. In 1848, the Health of Towns Association reported that the municipal water supply was “intermittent and very deficient”: Intakes were at “the lowest level of the city, and at the tail of nearly all the sewers” , and higProblematic sanitary arrangements came under pressure from the mid-19th century onward. Trained in statistical analysis and mobilizing the spectres of cholera and typhoid, a new generation of young politically engaged experts pushed for social and sanitary reform . In OxfoSanitarians’ reform proposals proved controversial: While the University’s commissioners supported the proposals, many town representatives opposed sanitarians’ plans, which the University refused to pay for and which would entail a loss of local autonomy and more central government interference . There wBetween 1849 and the 1860s, town and gown disagreements on the cause of Oxford’s disease problems and who should pay for removing them led to a wave of commissioned external sanitary assessments. Often conducted by civic engineers, whose professional interests closely aligned with those of sanitary reformers, resulting reports stressed the need for improved sanitation to remove putrefying and odiferous matter causing miasma and proposed various new sewerage infrastructures. However, ongoing power struggles meant that all were turned down for reasons of cost and disagreement on who should pay for change.While many of the city’s early engineering schemes focused on removing miasmatic causes of disease via sewage and drainage, Oxford’s drinking water also remained problematic. Although it stopped directly pumping drinking water from below sewage outlets in 1853, the city ignored advice for new waterworks to be situated upstream of Oxford and instead acquired cheap low-lying spring-fed gravel pits (formerly used for railway construction) close to its former intake and the cesspits of the rapidly expanding Hincksey neighborhood. The new water source was occasionally topped up with river water and could also be contaminated during floods. Despite improved pumping, simple gravel and sand filtration, and new cast iron pipes, municipal water’s cost and poor quality made the majority of Oxford’s poorer classes continue to favor wells and river water while University colleges benefited from slightly better arrangements with piped water being supplied from a higher spring on Hincksey Hill . With OxThe Lancet proclaimed: “There can be no doubt that at the present moment Oxford is not a safe place of residence, owing to the imperfect condition of its drainage and impure water supply” [The sanitary stalemate was only broken around 1870 by university typhoid outbreaks, central government pressure, and the availability of cheap credit . Between supply” . It was  supply” , 25.While frequent typhoid outbreaks in Oxford’s working-class districts rarely attracted much attention, cases among the student body reflected badly on both the University and senior municipal officials. At first, the University tried to assuage public criticism with stricter inspections by its commission for nonuniversity lodging houses (est. 1868) . HoweverThe long-term effects on typhoid incidence were pronounced. While diagnostic problems make misreporting and underreporting likely, contemporary data indicate a decline of typhoid mortality from a high of 15 cases (1878 and 1884) to virtually zero between 1908 and 1915, with particularly sharp dips occurring between the installation of improved sand filtration, new upstream water intakes, and the universal provision of municipal piped water (1883–1886). Data on typhoid incidence (available from 1898 onward) indicate a further sharp decline following the establishment of chlorination (1930) and the closure of the old water works (1934) . In keepHistorically, new scientific knowledge of waterborne transmission and bacterial causation thus played an important role in gradually changing local understandings of typhoid but was not the sole factor shaping the trajectory of municipal disease control measures. Instead, the combination of cheap municipal credit, scandals, and external pressure proved crucial in breaking down old rivalries around sanitary reform—be it to remove miasmatic filth or dangerous bacteria—and creating the financial capacity for a sustained program of municipal sewage and water systems expansion.Nonlinear responses to local disease problems also occurred in cities across the United States. Similar to Oxford, local experts frequently presented sanitation as a major cause for typhoid reductions, as well as reductions in overall mortality . HoweverDespite being influenced by British developments, American sanitary reform had a unique trajectory. Similar to Britain, the germ theory of disease was still hotly debated among US physicians and sanitary reformers prior to the mid-1880s . NeverthUntil the Second World War, US legal requirements for water disposal and treatment varied significantly . BeginniThe absence of national standards led to different municipal sanitation strategies. While Philadelphia built the first large-scale municipal water system in 1802 , there wTo test claims that municipal investment in water and sewer systems was associated with declining typhoid mortality , we extrDespite being <100 miles apart, the levels and patterns of typhoid mortality and transmission in Philadelphia and New York were very different . PhiladeNew York City, on the other hand, drew its water from rural watersheds and constructed aqueducts to carry it into the city . TyphoidChicago relied on Lake Michigan for its water supply, but the city’s sewage system drained directly into the lake via the Chicago River . As a reIn San Francisco, water supply and sewer systems were mostly privately owned. Water was obtained from wells, creeks, and springs owned and operated under the monopoly of the Spring Valley Water Company . The comDespite the significant variations of municipal sanitary, environmental, and technological interventions and their timing, the same concept emerges: increased and regular spending on sanitation systems was correlated with decreased typhoid transmission across US cities . In BritHistory offers a rich seam of data with which to evaluate various public health interventions. By fusing historiographic and epidemiological methodologies, we have come to 2 interrelated insights regarding the success of different typhoid interventions: (1) Effective sanitary infrastructures in Oxford and major US cities evolved not as a top-down and linear process of reforms but as a bottom-up response to local disease problems, social contexts, and power struggles in the relative absence of central government oversight; (2) in contrast to popular accounts’ emphasis on heroic moments of scientific and technological intervention, sustained financing of affordable water and sanitary infrastructures emerges as a crucial factor underpinning mid- and long-term disease control. In both Oxford and the United States, municipalities’ ability to take on affordable debt  incentivized the formation of local coalitions around sanitary reform, often well before national laws mandated clean water and waste water disposal. This account of locally tailored, nonlinear solutions, and cheap municipal debt provides important insights for the control of typhoid in the rapidly urbanizing cities of the 21st century.While the top-down health planning favored by international planners after 1945 could prove successful in nations with effective institutions and high levels of centralization, this policy approach often failed in areas characterized by high degrees of regional autonomy, weak government control, or lacking resources . In 2005


South East Asia is one of the world’s largest tobacco epidemic regions which tobacco smoking is known increase the risk of various diseases, including cancer. As data from GLOBOCAN 2018 has had released on September 2018, the aim of this study are to calculate the estimated burden of several types of cancer attribu to tobacco smoking in Association of Southeast Asian Nations (ASEAN) 2018 and compare it with established result data in 2012. So it can be highlight what has been achieved and what it needs to be addressed by member countries of ASEAN to strengthen cancer prevention against tobacco smoking. This study was using descriptive epidemiological incidence and prevalence-based research design to estimate the burden of 14 types of cancer attributable to tobacco smoking in member countries of ASEAN, in term of incidence and mortality. The cancer incidence and mortality data gained from GLOBOCAN 2018. According to the estimation, tobacco smoking was responsible for 121,849 new cancer cases in 2018  in ASEAN 2018. Our findings are mostly lower than previous study in 2012, both for cancer incidence and mortality in male and female. It seems more ASEAN member states are adopting effective policies in the MPOWER suite of interventions such as raising taxes on tobacco, establishing smoke-free areas and implementing graphic health warnings in decreasing number of tobacco smoking. Therefore, ASEAN member countries are strongly encouraged to strengthen the existing tobacco control measure in order to effectively gain a significant decline of tobacco smoking related cancer in the future. There are more than one billion tobacco users worldwide and 80% of them live in low and middle income countries. As per estimates, 246 million smokers and 290 million smokeless tobacco users in the World Health Organization (WHO) South East Asia Region which makes it one of the largest tobacco consuming regions , 2017). Those numbers are still become a global health problem, because both smoking and smokeless tobacco users have well known increase the risk of death from various diseases such as coronary heart disease, stroke, and respiratory disorders in adults, and many types of cancer which may increase the health burden of nations , 2011a)Smoking increases the risk of malignant tumors in nearly all organs with at least 30% of all cancer deaths smoking is attributed to smoking . Once tobacco has damaged cells, they can grow uncontrollably as cancer. When DNA is damaged, a cell can begin growing out of control and create a cancer tumor. This happens because poisons in tobacco smoke can destroy or change the cell’s instructions that might damage DNA in a way that leads to cancer . The long time lags for development of cancer associated with smoking, the impact of smoking caused diseases on mortality in many regions estimates will continue to rise for at least two decades , 2009).At present, there are 121 million adult smokers, approximately 10% of world’s smoker, in member countries of Association of Southeast Asian Nations (ASEAN) countries . ASEAN was established on 8 August 1967 and consists of eleven countries namely Brunei Darussalam, Cambodia, Indonesia, Lao PDR, Malaysia, Myanmar, Philippines, Singapore, Thailand, Vietnam, and Timor Leste in South East Asia region. The member countries have a combined population of approximately 625 million people, accounted for 9% of the world’s population .South East Asia is one of the world’s largest tobacco epidemic regions . Based on Kristina et al., (2016) study, tobacco smoking was responsible for about 131,502 cancer cases (28.4%) and 105,830 cancer deaths (30.5%) in ASEAN 2012 using data from GLOBOCAN 2012. As data from GLOBOCAN 2018 has had released on 12 September 2018  IARC, 2018), the aim of this study to calculate the estimated burden of several types of cancer due to smoking in ASEAN 2018 and compare it with result data in 2012. So through this study, it can be highlight what has been achieved and what it needs to be addressed by member countries of ASEAN to strengthen cancer prevention against tobacco smoking.This research was using descriptive epidemiological incidence and prevalence-based research design to estimate the burden of cancer due to smoking in members of ASEAN. There were three steps to gain the data; first we selected smoking-related cancer and estimated population-related smoking attributable fraction (SAF) using relative risks and prevalence of tobacco smokers in each member countries of ASEAN. Second, we find the number of incidence and cancer mortality of each country. Then lastly, we estimated smoking attributable incidence and mortality from the number of incidence and mortality multiply by SAF. Smoking prevalence The prevalence of current tobacco smokers among individuals aged 15 years and older, published by WHO global report on trends in prevalence of tobacco smoking 2000-2001, was obtained from Kristina et al., (2016) study . As the burden of cancer observed in 2018 reflects the past exposure of smoking, the prevalence in the year 2000 was used in our study due to long time lags for development of cancer associated with smoking , 2009). Timor Leste country prevalence of smoking was not included since the year of 2000’s data was not available. As shown in Selection of smoking-related cancerAccording to the level of evidences, we decided to include fourteen types of cancer with positive association with tobacco smoking shown by relative risk (RR) value more than one in this analysis, provided by Kristina et al., (2016) study. The cancer included cancer of lip and oral cavity (C00-08), nasopharynx (C11), others pharynx , esophagus (C15), stomach (C16), colorectal (C18–20), liver (C22), pancreas (C25), larynx (C32), lung cancer (C33–34), cervix uteri (C53), ovary (C56), kidney (C64–66), and urinary bladder (C67). Most RR of tobacco smoking-related cancer were in that study derived from recent meta-analysis , which consisted of 254 reports, of which 8 were from Africa, 28 were from Japan, 8 were from India, 39 were from China, 13 were from South America, and the others were from western countries . That global meta-analysis was selected because it is the most updated and there is no many meta-analysis conducted in Asia exists.Incidence and cancer mortalityThe number of cancer incidence and mortality in ASEAN member countries in 2018 were derived from GLOBOCAN 2018. GLOBOCAN is an online database from WHO International Agency for Research on Cancer (IARC) that providing estimates of incidence and mortality in 185 countries for 36 types of cancer , 2012). The methods of estimation are country specific and the quality of the estimation depends upon the quality and on the amount of the information available for each country. Incidence data are derived from national cancer registries . If country data is not available, estimation by modeling, using incidence mortality ratios derived from recorded data in country or local cancer registries is used. Mortality statistics were based on national data that are collated and made available by the WHO for countries with vital registration . Incidence and mortality from ten countries in Southeast Asia region were available, while Timor Leste data was not available yet for incidence and mortality of cancers in 2018. Estimation of smoking attributable fraction (SAF) of cancerTo calculate SAF values due to cancer, two parameters were considered: 1) the relative risks of tobacco smoking for the different related cancer, and 2) prevalence of smokers for male and female. The formula of SAF is shown below,where “p” is the prevalence of smokers in the national population, “RR” is the relative risk of illness due to tobacco smoking, sub-script-i is a category of disease. Exception for Singapore, due to there has been no any prevalence data of tobacco smoking, the SAF value gained and used directly from prevalence-based study of Gandini et al., (2008). Relative risks and SAF of countries members of ASEAN reported in Furthermore, smoking attributable cancer incidence in ASEAN member countries has shown in On the other hand, total cancer mortality in ASEAN due to tobacco smoking accounted for 94,312 which consisted of 83,472 and 10,840 cancer mortality for male and female respectively as shown in It is clear that cancer is an urgent global challenge that need prevention, early detection and diagnosis, treatment, and care services. Meanwhile tobacco consumption also remains a significant threat to public health and associated with different types of cancer . This study found that tobacco smoking was responsible for 121,849 new cancer cases in 2018  in ASEAN 2018. Our findings are slightly lower than previous study in 2012, with total of new cancer cases was 131,502 .On the other hand, the comparison of cancer mortality due to tobacco smoking of male between data from 2012 and 2018 is shown in Figure 1. From the figure, it can be seen that the cancer mortality was mostly lower in 2018 than 2012 for bladder, kidney, lung, pancreas, liver, colorectal, stomach, esophagus, pharynx and lip, oral cavity cancer. Only larynx and nasopharynx cancer have had higher number of mortality in 2012 than 2018. In addition, for female, cancer mortality was also mostly lower in 2018 than 2012 in bladder, kidney, lung, larynx, pancreas, liver, colorectal, stomach, esophagus, pharynx, lip, oral cavity cancer. Only female mortality of ovary, cervix uteri and nasopharynx cancer in 2018 were higher than 2012.Incidence data are produced by population based cancer registries. According to recent data compiled in Volume XI of the IARC’s Cancer Incidence in Five Continents, approximately 15% of the world population was covered by high-quality cancer registries around 2010, with lower registration in Asia only 6.5% of the total population . As well as for number of mortality, the recorded data from lower resource countries are the only relatively unbiased source of information on the distribution of common cancer types in a defined population. Lower number of cancer incidence and mortality between 2018 and 2012 in member countries of ASEAN may drive by different number cancer registries in those years. In addition, contemporary information on the fraction of cancer that potentially could be prevented, like tobacco smoking, is useful for priority setting in cancer prevention and control . For many years, WHO has worked with governments worldwide to strengthen policies, programs and strategies that prevent and reduce tobacco use, like MPOWER which measures assist in reducing the demand for tobacco products at country-level , 2013). Global experiences have revealed prevalence of tobacco smoking can effectively decrease with implementation of MPOWER policies . More member countries of ASEAN are showing leadership in adopting effective policies in the MPOWER suite of interventions such as raising taxes on tobacco, establishing smoke-free areas and implementing graphic health warnings .Report tracks implementation progress of tobacco tax policy against the WHO Framework convention on tobacco Control (FCTC) in 10 ASEAN countries . Southeast Asia tobacco Control Alliance (SEATCA) believes that better health of the population as result of higher excise taxes on tobacco will lead to better labor productivity, speedier economic development and to less suffering in the region (Southeast Asia tobacco Control Alliance (SEATCA), 2017). Evidence from India and Bangladesh suggested that taxation had significantly reduced tobacco use among adults . Price policies involving taxation have been also used to control smoking not only in Thailand but also in other countries around the world. In Thailand, consumption of Tobacco products was found to have decreased  relatively continuous in relation to that of other goods , 2011). Price policies through taxation to combat smoking have been very active over the period after 1996 in Thailand, consequently, Tobacco products have become relatively more expensive . In addition, communicating the health effects of smoking using vivid, large and prominent pictorial health warnings (PHWs) on Tobacco packages remains a primary goal of national Tobacco control policy. From a public health perspective, Tobacco packaging serves as the most cost effective communications channel for governments to convey the health risks of Tobacco use, especially among those with low literacy levels. To date, more than 80 countries and territories across the globe, including ten ASEAN countries, have analyzed PHW requirements in accordance to WHO FCTC. South East Asia is only region in the world where all its countries implemented PHWs on Tobacco packages  and constantly put efforts into the Tobacco control field with high commitment from the government, scientists and activists through MPOWER implementation . Therefore, ASEAN member countries are strongly encouraged to strengthen the existing Tobacco control (Centers for Disease Control and Prevention (CDC), 2012) measure in order to effectively gain a significant decline of Tobacco smoking related cancer in the future. ASEAN member countries need to further invest and innovate on Tobacco control and promoting healthy lifestyles to achieve the target on decrease number of cancer attributable Tobacco smoking. However, the study results may underestimate the overall proportion of cancer incidence and mortality attributable to Tobacco smoking, because many others risk factors associated with cancer such as diet, body mass index (BMI), and alcohol consumption  are not included in the research model and thus have the potential to cause bias. Furthermore, due to substantial economic development in ASEAN might be changed dramatically so that the SAF may need to be re-estimated in order to gain more accurate estimation. This study found that Tobacco smoking was responsible for 121,849 new cancer cases in 2018  in ASEAN 2018. Our findings are mostly lower than previous study in 2012, both for cancer incidence and mortality in male and female. More ASEAN member states are showing leadership in adopting effective policies in the MPOWER suite of interventions such as raising taxes on Tobacco, establishing smoke-free areas and implementing graphic health warnings. Therefore, ASEAN member countries are strongly encouraged to put in place stronger Tobacco control policies and to strengthen the existing Tobacco control measure in order to effectively control cancer in the future.