The post-conflict Acholi sub-region of Uganda is undergoing a period of transition that is influencing access, acceptability and use of family planning (FP). Low FP use and high unmet need for FP in Uganda's northern region provides a unique opportunity to test a community-based group counseling approach to reduce unintended pregnancies among young couples. We share findings from a proof of concept testing model in delivering fertility awareness methods (FAM) to groups of couples by trained non-health community youth agents.The group counseling model was developed for couples interested in two FAM-standard days method (SDM) and TwoDay Method-within rural communities in Northern Uganda. WALAN was tested in a three-month proof of concept phase, employing 24 direct observations of group counseling sessions; quantitative interviews with 9 couples using either SDM or TwoDay Method; 2 focus group discussions with youth facilitators, and; 9 key informant interviews with providers and leaders.The proof of concept results suggest model feasibility and acceptability among participating communities. Couples learned how to use FAM correctly. All 9 interviewed female users reported 100% correct knowledge of method use. Couples also reported high levels of satisfaction for both methods. SDM and TwoDay Method participants reported comfort and satisfaction in learning about FAM in small groups with other couples.The proof of concept phase confirmed intervention feasibility, albeit with some model adjustments. The results were used to inform the pilot intervention, launched in April 2016 within 15 other villages in the same region. To date, people in the post-conflict Acholi sub-region of Uganda are striving to rebuild their livelihoods and preserve the traditional familial and social structures that were eroded during 20 years of internal conflict. In this low resource setting, low contraceptive prevalence 24%) and high unmet need 34%)  are a re4%  are a% and higBackground on FAM: As part of WALAN, two FAM developed by the Institute for Reproductive Health, Georgetown University (IRH)-Standard Days Method® (SDM) and TwoDay Method®-were offered through a community-based group learning and counseling model to couples in districts of the Acholi region in Northern Uganda. As described in Intervention description: WALAN was designed as a community-based solution, offering both SDM and TwoDay Method in group counseling sessions. WALAN is implemented in partnership with Save the Children (SC) and the District Community Development Office, through the youth initiative for employment and sustainable livelihoods development (YIELD) project, an agricultural, vocational and apprenticeship training program. Through this platform, WALAN trains youth group members who participate in YIELD to become WALAN youth facilitators. In each implementing community, a pair of WALAN youth facilitators conducts a series of educational community learning sessions on human fertility, healthy timing and spacing of pregnancy (HTSP), LAM and FP. The community learning sessions have the dual purpose of providing fertility and HTSP information to the community at large, while also promoting FP services both within health facilities and through group counseling in SDM and TwoDay Method by the youth facilitators. During the community learning sessions on LAM and FP, participants are either invited to participate in a group counseling session on SDM or TwoDay Method, or are referred for other FP methods at the nearest health center, depending on their preference. Subsequently, group counseling sessions are offered by the youth facilitator pair to small groups of 4-5 couples who desire counseling in their FAM of choice, either SDM or TwoDay Method. After attending the group counseling session, couples are then encouraged to participate in follow-up method support sessions in which they discuss their experiences using the method, review method use, seek advice from their peer couples on potential challenges and encourage one another to use the method correctly. Finally, sensitization meetings are conducted with local community, cultural and religious leaders to ensure support for WALAN activities. Sensitization meetings are also conducted with health providers and Village Health Teams (VHTs) to strengthen linkages between WALAN community activities and referrals for FP services.A small-scale three-month proof of concept phase was tested from October 2015 to January 2016 to understand the delivery and acceptability of the community learning and group counseling model. For this phase, eight pairs of facilitators were trained on human fertility, FP/HTSP and FAM as well as co-facilitation skills to deliver community learning and group counseling activities across eight villages in the districts of Gulu and Nwoya. The purpose of the proof of concept testing phase was to determine (a) whether to continue moving the intervention forward into the next pilot phase and if so, (b) what changes should be made to increase the potential scalability and desired effect of the intervention. The testing phase aimed to answer the following three assessment questions: can trained community-based youth facilitators implement the WALAN community learning and group counseling session activities? Can couples learning about FAM through a group counseling session in their community gain the knowledge to use SDM and TwoDay Method correctly? What are community stakeholders? perceptions and acceptability of WALAN? A mixed methods design was used to answer the above questions, triangulating data from WALAN youth facilitators, FAM users and community key informants. Observational monitoring data were collected, including attendance records, session observations and facilitator debriefs. The team collected a total of 34 FAM user interviews (SDM and TwoDay Method) with 9 female users and 9 male partners at two time points (with two losses to follow-up), two focus group discussions (FGDs) with 16 youth facilitators, and nine key informant interviews (KIIs) with health service providers and community leaders. FAM user interviews with the 9 couples were collected approximately three weeks after participants attended their first group counseling session and again at a second follow-up point, six to eight weeks post-group counseling session. Female and male partners were interviewed separately; for every couple, the female user was interviewed first and then her permission was asked to interview the male partner.Results from interviews with FAM users, key informants and youth facilitators, in addition to session observations and facilitator debriefs illustrated four main findings about intervention reach, facilitator competence, couples' knowledge of method use and community acceptability. Each individual finding supports the feasibility of the group counseling model, although appropriate adjustments were made to the model as a result of these findings.Intervention reach: The proof of concept results show high demand for and interest in community learning and group counseling activities. In the period of three months, a total of 32 community learning sessions took place on fertility, HTSP and FP, and LAM across eight villages to approximately 498 participants. Of these, approximately 63% were female and 37% male; and about 61% to 76% had children. The majority of participants were young, with 51% of participants being 20-25 years old, 20% 15 to 19 years and 26% between 26 to 35 years of age. Only 2% were above 35 years. Below, Facilitator competence: During facilitators' activities in the community, external observers accompanied the pair of facilitators and applied a competency checklist to assess the delivery of community learning, group counseling and method support sessions. The competency checklist collected information on: counseling principles, facilitation skills, screening couples, teaching the method and supporting the couple to use the method. During SDM and TwoDay Method group counseling sessions, facilitators were ranked on the following categories: 1) Correct use of job aids; 2) Correct explanation of method; 3) Client screening; 4) Safe learning environment and; 5) Demonstration of essential skills. Each of the five categories was ranked as either, “Did well;” “Did partially;” or “Did not do at all.” A total of five SDM facilitator pairs and three TwoDay Method pairs were observed. In general, youth facilitators performed best in their use of job aids and ensuring a safe environment. Similar to the community learning sessions, both SDM and TwoDay Method facilitators almost unanimously scored perfectly on using their job aids and ensuring a safe counseling environment. One possible explanation could be that facilitators strengthened their skills in both areas due to their conducting community learning sessions the month prior to starting the group counseling sessions. Five of the six observed facilitators completed the screening for SDM eligibility correctly, covering both the cycle length as well as the couple agreement criterion. For TwoDay Method, however, only one of the three facilitators observed mentioned who is eligible to use the method. In addition, difficulties recruiting eligible users for the FAM user interviews below suggest that facilitators may need to improve screening. For instance, some participants who were contacted to participate in FAM user interviews had received the method but were either pregnant prior to attending the session or were post-partum and therefore were unable to use the method.Both SDM and TwoDay Method facilitators can explain the methods correctly: Both groups of SDM and TwoDay Method facilitators observed were able to cover the essentials of each method's daily use, with five out of the six SDM facilitators explaining how Cycle-beads work, including monitoring for short and long cycles. TwoDay Method facilitators similarly covered the essentials of secretions and how to identify the fertile days, with all three facilitators explaining these key points .Couples' knowledge of method use: Correct knowledge of method use was assessed by interviewing five SDM and four TwoDay Method couples at two time points. All five SDM female participants scored 100% correct knowledge of method use both at the first interview and again three weeks later at the second data collection point . Results from the proof of concept confirmed high levels of acceptability and willingness of both participants and users to recommend others in their social networks that they attend the community learning and group counseling sessions. Reasons for high acceptability across all FAM users, facilitators and leaders interviewed included the ability to manage or “control” the method, lack of side effects and the fact that access to these methods had been brought “closer” to the community. One key concern mentioned by leaders and service providers included addressing intimate needs and individual questions in a group environment. However, the focus group discussion results suggest that youth facilitators also provided a separate, private space for individuals and/or couples to address them privately about personal issues, outside of the group counseling setting.Correct knowledge of SDM and TwoDay Method use among users and facilitators' ability to deliver the sessions indicate that the curriculum and the process in which it was implemented were sufficient to test and move the intervention toward the pilot phase. Findings from the proof of concept phase were used to refine aspects of WALAN, which launched the pilot phase in April 2016. Pilot activities occurred in 15 villages within the Gulu, Nwoya and Amuru districts of Northern Uganda.FAM are modern FP methods, scientifically tested and proven effective ;FAM is widely offered in one-on-one counseling in facility settings by medical professionals as well as in community settings by community health workers;In Uganda, FAM are included in the national FP norms and guidelines and offered most often in community settings by local service NGOs.Whereas counseling in FAM is not a new phenomenon, FAM has never been tested in a group counseling session format delivered by non-health community youth agents;The group counseling model is also testing a couples counseling approach, bridging the evidence gap on best strategies to engage men in FP counseling and decision-making;This study shares a proof of concept methodology and process for testing a new FP counseling model, strengthening the evidence-base around process methodology and evaluations.The authors declare no competing interests.


The Exploration, Preparation, Implementation, and Sustainment (EPIS) model is an implementation framework for studying the integration of evidence-based practices (EBPs) into real-world settings. The EPIS model conceptualizes implementation as a process starting with the earliest stages of problem recognition (Exploration) through the continued use of an EBP in a given clinical context (Sustainment). This is the first implementation science (IS) study of the integration of EBPs into adolescent HIV prevention and care settings.This protocol (ATN 153 EPIS) is part of the Scale It Up program, a research program administered by the Adolescent Medicine Trials Network for HIV/AIDS Interventions (ATN), described in this issue by Naar et al. The EPIS study is a descriptive study of the uptake of 4 EBPs within the Scale It Up program. The goal of EPIS is to understand the barriers and facilitators associated with the Preparation, Implementation, and Sustainment of EBPs into HIV prevention and clinical care settings.The EPIS study is a convergent parallel mixed-methods IS study. Key implementation stakeholders, that is, clinical care providers and leaders, located within 13 ATN sites across the United States will complete a qualitative interview conducted by telephone and Web-based surveys at 3 key implementation stages. The Preparation assessment occurs before EBP implementation, Implementation occurs immediately after sites finish implementation activities and prepare for sustainment, and Sustainment occurs 1 year postimplementation. Assessments will examine stakeholders’ perceptions of the barriers and facilitators to EBP implementation within their clinical site as outlined by the EPIS framework.The EPIS baseline period began in June 2017 and concluded in May 2018; analysis of the baseline data is underway. To date, 153 stakeholders have completed qualitative interviews, and 91.5% (140/153) completed the quantitative survey.The knowledge gained from the EPIS study will strengthen the implementation and sustainment of EBPs in adolescent prevention and clinical care contexts by offering insights into the barriers and facilitators of successful EBP implementation and sustainment in real-world clinical contexts.DERR1-10.2196/11202 Over the past 25 years, behavioral scientists have developed a number of efficacious interventions to reduce HIV transmission and improve self-management among those living with HIV. Between 2003 and 2014, the overall incidence of HIV in the United States decreased by 25%, yet youth aged 13 to 24 experienced a 43% increase [Implementation science is the study of methods and factors influencing the translation of research and other evidence-based practices (EBPs) into routine care . MultiplThe Exploration, Preparation, Implementation, Sustainment (EPIS) model ,6 is an This paper describes the EPIS research protocol, a study being conducted by the Adolescent Medicine Trials Network for HIV/AIDS Interventions . EPIS is a mixed-methods implementation science (IS) research study of the uptake of 4 EBPs across the United States at ATN research sites. Thus, EPIS is 1 study within a larger program of research, “Scale It Up,” to improve HIV-related self-management among youth living with or at risk of contracting HIV . The 4 EThis study will use a convergent parallel mixed-methods design  with datAll medical providers and staff with patient contact (“Key Stakeholders”) at 13 ATN sites participating in the aforementioned Scale It Up research projects will be eligible to participate . PatientBefore each data collection effort, each site will provide a list of the medical providers and staff with direct patient contact. This list will include names, contact information (phone number and email), and role(s) within the clinic. Potential participants will receive an initial “enrollment email” introducing them to the EPIS model and study and providing them with instructions for scheduling their qualitative interview through a Web-based scheduling system. After the initial email, potential participants will be sent reminders every 2 weeks throughout the baseline study period about project enrollment. All sites have agreed to permit participants to participate in EPIS data collection efforts during their regularly scheduled work hours. Participants will be provided a list of available interview times from which they can choose an interview time most convenient for their schedule and availability. Participants will also be given the option of directly emailing their availability to arrange the most convenient interview. Interviewers are centralized, providing available times for all sites and will call participants at the scheduled time.Upon completion of the interview, participants receive a link to complete the survey in Qualtrics. Participants who complete both the qualitative interview and quantitative survey receive a US $10 Amazon e-gift card. If a participant completes all 3 assessments , they can receive a total of US $30 in Amazon e-gift cards. Participants who have not completed the quantitative survey will receive periodic reminders to do so for the duration of the data collection window.All study procedures were approved by the institutional review board of the Scale It Up principal investigator’s (PI) academic institution. All participants provided oral informed consent before the initiation of any study activity.Assessments will elicit participants’ perceptions of barriers and facilitators to EBP implementation and sustainment at 3 critical implementation phases: preimplementation (Prepare), postimplementation (Implementation), and sustainment. The baseline assessment (June 2017-March 2018) will capture preimplementation feedback on anticipated barriers and facilitators for the specific EBPs each site will be implementing. The first follow-up assessment will occur postimplementation (March 2019-February 2020) and will assess barriers and facilitators experienced during EBP implementation and query anticipated barriers and facilitators to sustaining the EBPs. The second follow-up assessment (March 2020-February 2021) will assess barriers and facilitators experienced during the initial (1 year postimplementation) sustainment period.Trained interviewers will conduct interviews by telephone using a semistructured interview guide. Interview domains will include gathering information about the participant’s professional background and experience, clinical site organization and structure, familiarity with EBPs in general, familiarity with the specific EBPs being implemented, and perceived barriers and facilitators to implementing the specific EBPs. In addition, site PIs will be asked about organizational history with EBPs, internal  and external (community and state) leadership structures, and their site’s political context (policies and funding mechanisms) and fiscal considerations. It is estimated that key stakeholder interviews will require 30 min to 60 min to complete. Site PI interviews will require 60 min to 90 min to complete and thus will be completed in 2 parts (30 min to 60 min each).Interviewer training will include prework for priming before the training and a 2-part live virtual training with modeling. Follow-up support will include interviewers conducting 2 mock interviews with self-assessment and trainer ratings and feedback following each mock interview; the rating forms were adapted from the study by Amico . InterviInterviews will be audio-recorded and, immediately upon completion of the interview, uploaded to a secure server for storage. Audio files will be electronically transferred to a professional transcription service. Transcriptionists will provide a verbatim, deidentified transcript of the interview. Deidentification will involve removing participant and clinic staff member names. Research staff will review transcripts for quality  and confidentiality  before releasing the data for coding. Interview data will be uploaded to NVivo Version 12  for analysis.Evidence-Based Practice Attitude Scale  [Appeal of EBP , likelihood of adopting EBP given Requirements to do so , Openness to new practices , and perceived Divergence from usual practice with research-based / academically developed interventions . They will also complete an updated version of the scale, the Evidence-Based Practice Attitude Scale-50 , which assesses 8 additional attitudinal domains [Limitations and their inability to address client needs , EBP Fit with the values and needs of the client and clinician , negative perceptions of Monitoring or supervision , the Balance of skills and the role of science in treatment , time and administrative Burden associated with learning EBPs , likelihood of increased Job Security or professional marketability provided by learning an EBP , Organizational Support for learning an EBP , and positive perceptions of receiving Feedback related to service delivery .Key stakeholders’ and Site PIs’ attitudes toward the adoption of EBPs will be assessed with the  Aarons) . The EBP domains . The EBPOrganizational Climate Measure  [Quality procedures , Training or a concern with developing employee skills , and Performance Feedback , which refers to the measurement and feedback of job performance. They will also complete the Implementation Climate Scale  [Focus on EBP , Educational Support for EBP , Recognition for EBP , Rewards for EBP , Selection for EBP , and Selection for openness . Key stakeholders will only complete the Perceived Organizational Support Scale  [Participants’ perceptions of organizational climate will be assessed with 3 measures. Key stakeholders’ and Site PIs’ perceptions of organization climate, in general, will be assessed with the n et al) . The OCMt et al) . The ICSs et al) . The POSDirector Leadership Scale,  [Implementation Leadership Scale  [Proactive leadership , Knowledgeable leadership , Supportive leadership , and Perseverant leadership .Key stakeholders and Site PIs will also evaluate the role of leadership in the implementation of EBPs using 2 scales: the e et al)  and the s et al) . The DLSSelf-Assessment of Fit in Schools [The extent to which the strategies, procedures, and elements of the 4 EBPs being implemented in the Scale It Up program match the values, needs, skills, and available resources  will be assessed with an adapted version of the  Schools . Key staImplementation Citizenship Behavior Scale  [Site PIs will assess the extent to which their staff contributes to EBP implementation by demonstrating behaviors that go beyond minimum requirements using the t et al) . The ICBThe analyses will focus on understanding the barriers and facilitators located within sites’ inner and outer context that is associated with implementing and sustaining EBPs into HIV care settings. Analyses will be guided by the following questions: (1) How do inner context factors  influence EBP implementation and sustainment? (2) How do outer context factors  influence EBP implementation and sustainment? (3) To what extent do the perceptions of key stakeholders and clinical leaders  vary, and how does that variation affect EBP implementation and sustainment? (4) To what extent do stakeholder perceptions (key stakeholder and site PI combined) vary by site ?First, consistent with Morgan’s  recommenThe coding team will be led by the EPIS study PI, an experienced PhD-level mixed-methods researcher. A total of 3 coders, 2 research assistants with, at minimum, a baccalaureate degree, and 1 postdoctoral fellow with qualitative coding experience will code all the data. Coders will undergo initial training to familiarize themselves with the EPIS model, its constructs, and the operational definitions developed for the study. Coders will also be trained in the analytic approach, including the coding software. Coders will first collaboratively code 6 interviews (3 site PI and 3 key implementers) to familiarize themselves with the data and finalize the working codebook. An initial assessment of intercoder reliability will be conducted on 2 interviews (1 site PI and 1 key implementer). Coders will not be released for independent coding unless their intercoder reliability is at a minimum of 0.60 or higher as assessed by Cohen kappa . To ensuThe coded data will be comparatively analyzed both within and across time to examine differences at the setting and provider-level in quality and extent of EBP implementation. Examining the segments of text that are associated with differences in the frequency of categories between, for example, high-fidelity and low-fidelity sites, and examination of patterns in the presence and absence of thematic categories will allow us to provide empirically grounded explanations for differences in study outcomes.Analysis will begin by examining the psychometric properties, for example, internal consistency reliability using Cronbach alpha for all scales and subscales of established measures. Measures demonstrating insufficient reliability  in the study sample will be further examined with an exploratory factor analysis using Promax oblique rotation. Items with loadings <.40 or strong cross-loadings may be excluded for further analyses. Intercorrelations among items within each subscale and subscales within each measure will be examined; the correlation among measures will also be examined. Once reliability in the sample is established, descriptive analyses will be used to summarize the inner and outer contextual factors within and across sites and by informant . At baseline, we will examine mean differences in perceptions of intervention fit and attitudes toward EBP across site PIs and key implementers. We will also assess how perceptions vary as a function of Implementer demographics. At each follow-up, a comparison of changes in the inner and outer context factors over time  using a multivariate analysis will be conducted. Mixed linear effects models, adjusting for covariates, including age, time in position, role in clinic, experience level, and site-level factors, will be used to explore the impact these factors have on the overall implementation and sustainability of Scale It Up projects across sites and patient outcomes.To offer findings in ways that move beyond the particularistic view of EBP implementation within the sites, once all of the data are coded across all time points, we will adopt the innovation profile approach  originalEPIS data collection was launched in June 2017 and, at the writing of this paper, the first phase (Preparation) of data collection has concluded, and analyses are underway. A total of 140 of 282 eligible stakeholders completed both components of the first EPIS data collection. The baseline data collection window closed with a small proportion of providers  having partially completed the baseline assessment, that is, the qualitative component was completed, and the quantitative survey remains outstanding. About 20% (56) declined to participate and the remaining stakeholders did not respond to the enrollment invitation before the closure of the baseline data collection window. Although EBPs have demonstrated success in the academic setting, many challenges can prevent an EBP’s successful implementation and sustainment in real-world clinical contexts. The goal of the EPIS IS study is to generate knowledge about the barriers and facilitators to the implementation and sustainment of EBPs into adolescent HIV prevention and clinical care settings. Understanding the factors that impact organizations, clinics, and practitioners throughout the EBP implementation process will facilitate the adoption of EBPs by tailoring implementation to fit within the needs and culture of the organization and/or clinic.The EPIS sample is limited to the 13 participating ATN clinics and the medical providers and staff with direct patient contact within these clinical settings. These participants may not be representative of service providers in other contexts. This study and the Scale It Up program are focused on the implementation of EBPs in multidisciplinary adolescent HIV settings. The EPIS model was developed in child welfare ,37 and hThis study is the first IS study of EBP implementation in adolescent HIV settings. The knowledge gained from the EPIS study will strengthen the implementation and sustainment of EBPs in both adolescent prevention and clinical care contexts by offering insights into the barriers and facilitators of successful EBP implementation and sustainment in real-world clinical contexts.


The Systems Biology Graphical Notation (SBGN) is an international community effort that aims to standardise the visualisation of pathways and networks for readers with diverse scientific backgrounds as well as to support an efficient and accurate exchange of biological knowledge between disparate research communities, industry, and other players in systems biology. SBGN comprises the three languages Entity Relationship, Activity Flow, and Process Description (PD) to cover biological and biochemical systems at distinct levels of detail. PD is closest to metabolic and regulatory pathways found in biological literature and textbooks. Its well-defined semantics offer a superior precision in expressing biological knowledge. PD represents mechanistic and temporal dependencies of biological interactions and transformations as a graph. Its different types of nodes include entity pools  and processes . The edges describe relationships between the nodes . This document details Level 1 Version 2.0 of the PD specification, including several improvements, in particular: 1) the addition of the equivalence operator, subunit, and annotation glyphs, 2) modification to the usage of submaps, and 3) updates to clarify the use of various glyphs .


In Burkina Faso, the coverage of services for family planning is low due to shortage of qualified health staff and limited access to services.Following the launch of the Ouagadougou Partnership, an alliance to catalyse the expansion of family planning services, the health ministry created a consortium of family planning stakeholders in 2011. The consortium adopted a collaborative framework to implement a pilot project for task sharing in family planning at community and primary health-care centre levels in two rural districts. Stakeholders were responsible for their areas of expertise. These areas included advocacy; monitoring and evaluation; and capacity development of community health workers (CHWs) to offer oral and injectable contraceptives to new users and of auxiliary nurses and auxiliary midwives to provide implants and intrauterine devices. The health ministry implemented supportive supervision cascades involving relevant planning and service levels.In Burkina Faso, only 15% (2563/17 087) of married women used modern contraceptives in 2010.Adoption of new policies and clinical care standards expanded task sharing roles in family planning. The consortium trained a total of 79 CHWs and 124 auxiliary nurses and midwives. Between January 2017 and December 2018, CHWs provided injectables to 3698 new users, and auxiliary nurses or midwives provided 726 intrauterine devices and 2574 implants to new users. No safety issues were reported.The pilot project was feasible and safe, however, financial constraints are hindering scale-up efforts. Supportive supervision cascades were critical in ensuring success. We used the World Health Organization’s (WHO’s) In Burkina Faso, only 15% (2563/17 087) of married women used modern contraceptives in 2010, with 20-percentage points difference between urban (31%) and rural areas (11%). The unmet needs for family planning were estimated at 24% (4069/17 087) with also a rural versus urban gap.Some form of task sharing in family planning have existed in the country since the Declaration of Alma Ata in 1978. At the community level, community health workers (CHWs) can counsel clients, distribute condoms and resupply women with oral contraceptives. At the primary health-care centre level, auxiliary nurses or auxiliary midwives can provide short-acting contraceptive methods, including injectable contraceptives. However, health policies and clinical care standards prohibited them to perform more complex tasks. CHWs could not prescribe oral contraceptive pills to new users and provide injectable contraceptives, and auxiliary nurses or midwives could not insert and remove implants or intrauterine devices.Association Burkinabé pour le Bien-Être Familial, Équilibre et Populations and Marie Stopes International. Partners agreed on a framework centred on collaboration and committed to specific responsibilities in their respective areas of expertise, such as advocacy, capacity development of CHWs, auxiliary nurses and auxiliary midwives and monitoring and evaluation.Following the Ouagadougou Partnership launch in 2011, the health ministry created a consortium of family planning stakeholders comprising nongovernmental organizations (NGOs), including Between 2017 and 2018, the consortium conducted a pilot project for task sharing in family planning in Tougan and Dandé, two rural districts located in different regions of the country. A total of 25 primary health-care centres and their catchment areas were included in both districts. The strategic approach encompassed an advocacy strategy for changes in policies and clinical care standards; community outreach activities to increase the demand for services; and staff capacity strengthening at both community and primary health-care centre levels. All the activities were conducted in close collaboration with the district level health ministry. To change health policies and clinical care standards for supporting task sharing in family planning, the consortium developed an advocacy strategy in 2012, which was based on the regular review of scientific evidence, including data from the field, during consortium meetings. The consortium established a steering committee to oversee the entire project. In addition to senior representatives of the health ministry and implementing NGOs, this committee comprised key partners at country level, including WHO, the United Nations Population Fund and the United States Agency for International Development. The consortium shared evidence on task sharing in family planning, through oral presentations and written summaries with the committee and during meetings with authorities at the provincial, regional and national levels before the project started as well as providing new results on the project’s feasibility, effectiveness and patient safety during the project.Association Burkinabé pour le Bien-Être Familial was responsible for demand creation activities by training CHWs to conduct more home visits and discussions with increased focus on family planning at the community level. CHWs learnt counselling and the delivery of key messages during the capacity strengthening workshops. CHWs visited community events, such as market days, to deliver the key messages to relevant audience. Demand creation was also facilitated by strengthening the capacity of auxiliary nurses and midwives for quality counselling at facility level, which was included in their capacity strengthening workshops.Association Burkinabé pour le Bien-Être Familial led the training of CHWs. These providers were already working in different programmes, such as home management of malaria or undernutrition screening and had been recruited by the health ministry. Their monthly incentive approximates 40 United States dollars and they did not receive additional payment for the additional tasking sharing. The association organized two sessions in Dandé and three in Tougan. During the two-week workshops, for which the participants had to leave work, they received training on family planning counselling and the provision of condoms and oral and injectable contraceptives. The training method included interactive presentations, group work, role-play and practical sessions in health facilities.With the support of the other members of the consortium, Marie Stopes International facilitated the training of auxiliary nurses and midwives on implant and intrauterine device counselling, insertion, and removal. Two workshops were organized in Dandé and three in Tougan. Each workshop lasted two weeks, had full training days and used interactive presentations, group works and practical sessions.Équilibre et Populations coordinated the implementation of the agreed monitoring and evaluation plan, which included monitoring service provision issues on both client and provider sides, reviewing periodic and final project reports, and ensuring the implementation of recommendations.The health ministry and NGOs created a supportive supervision strategy, cascading from the national level to the community and primary health-care centre levels . This caThe advocacy process raised awareness of relevant actors, which contributed to the adoption of new policies and clinical care standards allowing CHWs to prescribe oral contraceptives and provide injectable contraceptives to new users at the community level and auxiliary nurses and midwives to offer implants and intrauterine devices at primary health-care centres.Between January 2017 and December 2018, the consortium trained a total of 79 CHWs and 124 auxiliary nurses and midwives and implemented the pilot project that resulted in an increase in the numbers of new family planning users in both districts. From February 2017 to December 2018, CHWs provided injectables to 3698 new contraceptive users and auxiliary nurses or midwives provided 726 new intrauterine devices and 2574 new implants . During Gathering different family planning stakeholders within the same country to plan and act collaboratively contributed to increasing access for women and couples to a wider range of contraceptive methods and to meeting the demand of women and couples for family planning.The iterative evidence-based advocacy efforts proved useful in changing policies and clinical care standards. The pilot project reinforced the existing evidenceBox 1• Task sharing in family planning was feasible and safe at both community and primary health-care centre levels.• Mobilizing key stakeholders catalysed changes in health policies and clinical care standards related to task sharing in family planning.• Participatory supervision cascades under the leadership of the health ministry was critical in ensuring the success of the project.There were challenges to the task sharing project. First, the high turnover of auxiliary nurses and midwives in the project areas was an issue, which the consortium addressed by offering training sessions to newly arrived auxiliary nurses and midwives. This issue will likely have less impact once this task sharing is implemented in the whole country. Second, the long-term sustainability of task sharing in family planning at the community level requires further study, as CHWs are not yet fully integrated into the formal health system and limited salary incentives affect their motivation. Third, primary health-care providers equipped with additional competencies may legitimately wish for a better salary. Fourth, following the overall positive processes and outcomes of the pilot project,Countries facing similar challenges in coverage of family planning services could implement an equivalent strategy so that women and couples can have access to a wider range of safe contraceptive services that better meet their needs.


Background: Societal capacity to address the service needs of persons with concurrent mental health and substance-use disorders has historically been challenging given a traditionally siloed approach to mental health and substance-use care. As different approaches to care for persons with concurrent disorders emerge, a limited understanding of current models prevails. The goal of this paper is to explore these challenges along with promising models of coordinated care across Canadian provinces.Materials and methods: A scoping review of policies, service coordination and access issues was undertaken involving a review of the formal and gray literature from 2000 to 2018. The scoping review was triangulated by an analysis of provincial auditor general reports.Results: Models of concurrent disorders service were found to have evolved unevenly. Challenges related to the implementation of models of collaborative care and local networks that foster service coordination and policy accountability were found to inhibit integrated care.Conclusion: Emergent models of coordinated care were found to include collaborative care, regional networks with centralized access to care, clinical information-sharing, cross-training, improved scope of care to include psychologists and alignment of physician incentives with patient needs to better support patient care. Co-occurring mental health and substance-use disorders disable one-third to one-half of treatment populations with an estimated international prevalence of 1–3% . A largeThe Canadian population affected by concurrent disorders (1.7%) accounts for a large proportion of those using mental health and substance use (MHSU) services . Concurr*(asterisk). We screened all the publications for eligibility based on relevance by reviewing the title and abstract. We included qualitative and quantitative studies focused on Canada as well as gray literature, commentary, proposals and editorials in the Canadian context. The language of publication was limited to English for reasonable analysis purposes. Studies in which participants were elderly people over 75 years of age were excluded. The PRISMA-P criteria for reporting a scoping review protocol was followed , Cochrane Methodology Register), Health Technology Assessment Database, and Web of Science . Search terms included substance use/misuse/abuse, drug addiction, addiction therapy, substance use/misuse/abuse therapy, mental health services supports/treatment, concurrent disorders/mental health/substance use, substance use policy, concurrent disorder policy, concurrent disorder financing/funding, access to services, comorbidity. The search terms were used in combination with the Boolean operators AND, OR, and followed . In addiData were recorded based on participant characteristics , addressed access to concurrent disorder service support/treatment programs, coordination of MHSU care and policy. Study quality was assessed using a checklist and included assessment of control group and randomization (for intervention studies), objectivity of outcome measures, validity, adequate methods of analysis , and description of the demographic.The screening and selection process for the scoping review are shown in Considerable emphasis was placed on improving access to MHSU services across the provinces. Rush and Saini  identifiStrengthening mental health care within primary care and integrating care between providers are key issues . IntegraOpen Minds, Healthy Minds, Ontario's Comprehensive Mental Health and Addiction Strategy (2011) emphasize the difficulty for individuals to navigate and access services because of the “silo” approach in the healthcare system  stressed that “patient centered integration is the right thing to do for patients, and for our healthcare system”  are being piloted to improve service standards and models of care for youth aged 12–25. The goals include increased access to timely, integrated mental health and addictions services for adolescents and transition-aged youth. Elements of the model include evidence-based services matched to individual need, co-located MHSU and primary care, improved holistic care, system functioning and mental well-ness outcomes . FundingDespite an expansion of Early Psychosis Intervention (EPI) programs for youth in Ontario, a retrospective cohort study by Kozloff et al.  found 40An estimated 35,000 people are homeless on any given night and 235,000 experience homelessness over a year in Canada . A signiFleury et al.  found thThe goals of Housing First services include reduction of unnecessary hospitalization and ED visits . Althougprocess that systematically arranges patient care across professionals and organizations; and integrated care as an outcome of the patient experience. Of four types of integration , organizational integration brings several organizations together through mergers or coordinated provider networks. Functional integration involves integrating administrative functions through for example shared electronic patient records. Service integration connects different clinical services at an organizational level through multidisciplinary teams for example. Clinical integration fosters a single, coherent care process by using shared guidelines  that emphasized better coordination across the health system would help reduce avoidable ED visits and long waits for mental health and addiction services  between organizations without a formal mechanism of coordination , while in an alliance autonomous organizations form a coalition  found that regional networks with strong governance and diversified resources supported better coordination of care and patient outcomes . SimplifHenderson et al.  demonstrA shift is needed in how MHSU treatment is conceptualized, organized, and funded . System Torchalla et al.  examinedIn Quebec, Fleury et al.  evaluateMcKee's  researchImportant sub-themes for integration and coordination were scope of practice and gaps in care. As primary care practices (PCPs) prescribe between 60 and 80% of psychotropic medications they play an important role in integrated care, where the same team treats physical and mental health problems and can achieve improved depression outcomes. Receiving services from PCPs can be less stigmatizing, more coordinated and more accessible than mental health specialist services. Ontario employees who received integrated care had fewer short-term disability days and returned to work faster. Integrated care was associated with shorter referral delays, reduced time in treatment, fewer appointments and lower treatment costs and addressed both mental health and substance use needs, which is important given the high rates of concurrent disorders . As the Medical school and continuing education on substance use is considered inadequate, inconsistently applied and a low priority. Physicians cite a lack of confidence in their ability to offer these services. As the optimal management of many addictions  involves a combination of pharmacological strategies and psychotherapeutic interventions that can increase the time needed for communication, physician practices may be deterred from offering them.Although physicians engaged in integrated care express concerns about liability insurance issues, the Canadian Medical Protective Association (CMPA) that provides liability protection argues that while fear of increased medico-legal liability is cited as a barrier to health professionals working collaboratively, there is no need for extensive changes to the medical liability system . They emKurdyak et al.  assessedAlthough models of collaborative care vary, they enable MHSU and primary care providers to work together more effectively to improve care. A position paper by Kates et al.  identifiAssertive Community Treatment (ACT) offers an alternative model in which an inter-disciplinary team of 10–12 practitioners accept shared responsibility to offer care to a caseload of 60–100 patients. Instead of coordinating services across agencies, the team delivers services directly in community settings to facilitate in crisis support, treatment and rehabilitation. Treatment populations are generally among the most seriously ill, including those with concurrent disorders and those who have been committed to community treatment . As ACT The historical separation of substance-use from mental health services has limited health professionals' scope of practice for concurrent disorders and produced gaps in care. Psychological services available to children are limited . The MenThe National Psychiatry Waiting List Survey indicated the average wait-time for “urgent referrals” made by family physicians to psychiatrists was 2-weeks, while the wait-time for “elective referrals” was 7-weeks . The ICCN = 1,275) practicing in Quebec advocated for greater accessibility to publicly funded psychotherapy  on their treatment and referral practice for adults with significant anxiety or depressive symptoms. Low referral rates were found; 61% of physicians treat over 50% of anxiety or depressive patient symptoms in their practice , jurisdictions shifted away from institutions and decentralized mental healthcare . In the Patients First Act (2016) and amendments to the Local Health System Integration Act (2006) equipped LHINs to better integrate healthcare systems by expanding the scope of a “health-service provider” under a LHIN to include Family Health Teams  could have addressed the growing need for broader health insurance by making coverage for non-physician health and mental healthcare providers such as nurses and psychologists a condition of federal funding transfers, instead it only addressed the issue of extra billing. The MHCC  recognizMaking the Case for Investing in Mental Health anticipated that such investments would reduce MHSU expenditures by over $179 billion and reduce employer expenditures due to productivity loss by $76.1 billion. Without increased investment, the MHCC  estimates that public funding from government transfers would need to increase to $3.1 billion per year, with an incremental base funding increase of $310 million each year, to close the MHSU gap and increase the share of mental health spending from seven to nine percent, with additional investments in social spending as the National Mental Health Strategy advised , 94. Thethe MHCC  predictsWith $5 billion in new federal funding to improve access to mental health services set to roll out over the next 10 years through the 2017 Health Accord, the window of opportunity could begin to close the long-standing gap in mental health funding. Bartram's analysis of potential accountability mechanisms advises tying targeted federal funds to specific initiatives, population groups or levels of evidence , 94.An analysis of the literature on emergent models of service across Canada revealed that individuals with concurrent disorders present with complex needs that are often difficult to treat . A majorTwo general approaches to achieve service-level integration were identified: co-located MHSU services or collaborative care models across MHSU service providers . SuccessLessons can be drawn from the barriers to concurrent MHSU care found and evidence concerning successful implementation strategies for integrated care models and the service networks on which they rely. The findings suggest formal network decision-making supports, implementation strategies and accountability mechanisms that monitor progress in implementing system reform would improve access to care. Despite limited progress made to integrate mental health with substance-use care, issues of policy accountability for system-level integration inhibit the delivery of coordinated care. Greater attention to operationalize and implement integrated service networks to address unmet MHSU needs and related harms requires changes to the funding and structure of provincial MHSU healthcare systems. At the governance level, funding incentives for providers should better align with the care needs of patients.A paradigm shift in which providers are seen as an integral part of a broader system of collaborative MHSU care reflects the future. This entails supporting providers to be part of a team, educating them on the opportunities to refer patients to related care providers such as early psychosis and substance use therapy, as well as an openness to accept referrals from community-based providers to better meet patient needs . This coOur assessment of the challenges in accessing coordinated MHSU care included a broad range of literature that was triangulated with an analysis of auditor general reports to counter potential bias. A number of limitations nonetheless remain. First, the review was limited to the search of English language studies even though research on coordinating MHSU care has been conducted in French speaking provinces. Moreover, the analysis may be somewhat unbalanced given the number of studies based in Ontario. Although auditor general reports from Alberta and Ontario were most referenced, findings from many other provinces were included . The results may also not be generalizable outside Canada as the design of healthcare systems varies across countries . Lastly, despite our attempt to conduct a thorough literature search, it is possible we missed studies on models of MHSU care in our analysis.MW conceptualized the study and introduction, contributed to the analysis of the literature and auditor general reports, and substantively edited the manuscript. AA conducted the literature search and analysis, wrote the methods, developed the decision tree, table summarizing the studies included and first draft of the results. KD analyzed the auditor general reports, contributed to the analysis of the literature, developed the discussion and conclusion and organized the references. SB contributed to the conceptualization of the study, supported the literature search, decision tree, and critically edited the manuscript.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Metabolic syndrome is a prevalent condition with dramatic rising trend worldwide. Single dietary factors, such as omega-3 fatty acids consumption protect body against oxidative damage by reinforcement of dietary total antioxidant capacity but the combination of all dietary components may be more effective when studied as integrated dietary patterns. This present study was designed to assess the association between different dietary patterns and oxidative stress in a population of Tehranian adults suffering from metabolic syndrome.Dietary data were collected using a validated 147-item semi-quantitative FFQ with a standard serving size. Factor analysis method was used to derive dietary patterns. Blood analysis and anthropometric measurements were also obtained. Oxidative stress was assesses using serum levels of Malondialdehyde (MDA) and total antioxidant capacity (TAC). The regression coefficient for TAC and MDA with different quintiles of dietary patterns, adjusted for potential confounder in model 3 reveal a significant positive association between healthy pattern and serum TAC levels  and also between serum MDA levels and the unhealthy pattern . On the other hand, a significant negative association found between serum TAC levels  and the unhealthy pattern, a relationship also noted between serum MDA levels and the healthy dietary pattern .Our findings suggest that following a healthy pattern filled with fruits and vegetables ameliorates oxidative stress status and on the contrary, attachment to an unhealthy pattern, characterized by higher intakes of fast foods and processed foods, aggravated the oxidative stress levels in Tehranian individuals suffering from metabolic syndrome. Metabolic syndrome (MetS) is a prevalent condition worldwide. Its prevalence of the MetS in Europe, Asia, Australia, and North and South America ranges between 13.4% and 70.0%, by the World Health Organization (WHO) definition . RegardlAlthough a number of expert groups such as WHO, ATP III and European Group for the Study of Insulin Resistance (EGIR) have proposed different definitions for MetS diagnosis, their focus has been on similar criteria such as elevated fasting blood sugar (FBS) and triglyceride, high blood pressure, decreased high density lipoprotein (HDL) cholesterol and emerging obesity , all conOne of the potential risk factors for some comorbidity such as MetS and T2D is oxidative stress. So, many studies are trying to find a way to detect, treat and prevent MetS with a focus on reducing oxidative stress as one of the important factors . It has Diets rich in whole grain cereals, fruits, and vegetables, with low animal-fat consumption, seem to confer prevention against cardiovascular disease risk factors, like hypertension, hypercholesterolemia, and obesity . HoweverSince it has been hypothesized that the combination of all dietary components may be more effective when studied as integrated dietary patterns, and also there is a lack of data on role of different dietary patterns in oxidative stress in patients with MetS, this present study was designed to assess the association between different dietary patterns and oxidative stress in a population of Tehranian adults suffering from MetS.th phase of TLGS. The study was approved by of the Ethics Committee of the Research Institute for Endocrine Sciences, Shahid Beheshti University of Medical Sciences and all participants provided written informed consent prior to enrollment of this study. Among 12823 people aged between 20 and 60 years in phase 4 of TLGS, the subjects diagnosed with MetS, according to ATP III criteria, were selected; those whose caloric intakes exceeded 4200 or were less than 800 kcal were excluded. This study was carried out within the framework of the Tehran Lipid and Glucose Study (TLGS), a prospective survey conducted on a large sample of Tehran residents. The aim of TLGS was to determine the prevalence of non-communicable disease risk factors and to encourage healthier lifestyles to ameliorate these risk factors, using data from the 4The TLGS study protocol and laboratory procedures have been published earlier . All subMetabolic equivalent (MET) was calculated according to the compendium of physical activity , and METAll samples were analyzed under the internal quality control supervision of the acceptable criteria. Inter- and intra-assay coefficients of variation were 2 and 0.5% for total cholesterol and 1.6 and 0.6% for TGs, respectively. To measure Malondialdehyde (MDA) concentration, lipid peroxidation qssay kit  was used. Total antioxidant capacity of plasma was measured using TAC assay kit  according to manufacture protocol.Dietary data were collected by trained dietitian with at least 5 years of experience in food consumption survey, using a validated 147-item semi-quantitative food frequency questionnaire (FFQ) , based ost and 5th quintiles of each dietary pattern, 100 subjects who had greatest and lowest adherence to the related dietary pattern were randomly chosen, giving us a study sample of 400 subjects with MetS.The healthy dietary pattern was high in fruits and dried fruits, olives, high- and low-fat dairy products, poultry and fish, liquid oils, and canned products, whereas unhealthy dietary pattern was dominated by carbonated drinks, fast foods, salty snacks, mayonnaise and organ meats. Dietary pattern scores were categorized into quintiles. Definition: Patients were assessed for having MetS according to ATP III criteria  were adjusted. All statistical analysis was done by SPSS software . P-values < 0.05 were considered as significant.On the other hand, subjects who had greater adherence to unhealthy pattern, compared to those with the lowest adherence, had significantly higher intakes of cholesterol, saturated fatty acids, monounsaturated fatty acids and polyunsaturated fatty acids, but had lower intakes of carbohydrates and fiber (p<0.05). Serum levels of TAC and MDA in the first and the fifth quintiles of both healthy and unhealthy patterns are demonstrated in Serum levels of TAC increase with greater adherence to the healthy pattern (p=0001) and there is an inverse association for followers of unhealthy patterns (p=001). There was also a significant trend for MDA and both dietary patterns, that in followers of the healthy pattern, its levels were lower, whereas elevated levels of MDA were seen in individuals with unhealthy dietary pattern . The regression coefficient for TAC and MDA with different quintiles of dietary patterns, adjusted for potential confounder in model 3  reveal aThe main finding of this study was the strong and significant association of TAC with both dietary patterns. TAC levels rose gradually with higher compliance to the healthy diet and a similar negative trend was noted for the unhealthy pattern, indicating that the healthy pattern has higher levels of antioxidants, while the unhealthy diet has lack in antioxidant. These associations remained significant at 2 levels of adjustments for age, sex, physical activity, BMI, and smoking, findings to be expected as followers of the healthy pattern reported more servings of fruits, vegetables and olive products known to be rich in antioxidants and also found in abundance in the Mediterranean diet, which is known to be associated with elevated TAC levels and low ox-LDL levels . In a coIt appears that the relationship between serum MDA and dietary pattern is reported for the first time in this study. Plasma levels of MDA were inversely associated with the healthy pattern, such that with increased compliance with the healthy pattern, MDA levels decreased in a stepwise manner; the compatible relationship was found for plasma MDA and the unhealthy pattern, demonstrating the increase of oxidative stress with greater adherence to unhealthy pattern. Moreover, these associations remained significant after adjustment for potential confounders  which indicates the independent nature of this finding. Data available on relationship between diet and MDA mostly focus on single nutrients or food items. A cross-sectional study of HIV-positive patients suggested that among other antioxidants, dietary selenium intake was strongly and inversely associated with plasma MDA . In anotThe beneficial effects of diet in ameliorating symptoms of MetS have been previously studied -27. In aNonetheless, the role of uric acid in conditions associated with oxidative stress is not entirely clear and some studies find this pro-oxidant role of uric acid . To imprA case-control study comparing the oxidative stress levels in patients mostly with type I diabetes with normal controls; reported that in diabetic patients, blood levels of antioxidants are not related to their dietary intakes but to serum lipids; although the low number of subjects (30 subjects) and the fact that most of them had type I diabetes make the results very difficult to generalize, results showed that dietary antioxidants do not have the same effect in all people ; TherefoAntioxidants, including vitamins such as b-carotene, vitamin C, and vitamin E, and the minerals selenium and zinc, abundantly found in foods like fruits, vegetables, fish, and olive, can diminish the oxidative process by inactivating free radicals and may provide a protective effect for the organism against MetS and its complications. Nevertheless, some studies show no beneficial effects of antioxidant supplementation on incident of MetS in generally well-nourished populations , 41, 42.This study has some limitations. One of which is the use of FFQ that relies on the long term memory of individuals, and exposes the outcome to memory bias. Although this FFQ has previously been validated in the same population, applying a predefined FFQ limits the number of food items for subjects. Our budget limitation forced us to limit the number of enrolled subjects in this study; however, the longitudinal design of this study is a major strength. This design removes many of the biases seen in other designs, such as cross-sectional, because subjects are unaware of any change in their oxidative stress status when they report dietary intake. In conclusion, according to our results the healthy dietary pattern with plenty of fruits and vegetables can ameliorate oxidative stress status by reducing MDA and increasing TAC and on the contrary, adherence to the unhealthy pattern, characterized by the higher intakes of fast foods and processed foods, aggravated the oxidative stress levels in Tehranian individuals suffering from metabolic syndrome.


Menopause is an age-dependent physiological condition associated with a natural decline in oestrogen levels, which causes a progressive decrease of muscle mass and strength and bone density. Sarcopenia and osteoporosis often coexist in elderly people, with a prevalence of the latter in elderly women. The profound interaction between muscle and bone induces a negative resonance between the two tissues affected by these disorders worsening the quality of life in the postmenopausal period. It has been estimated that at least 1 in 3 women over age 50 will experience osteoporotic fractures, often requiring hospitalisation and long-term care, causing a large financial burden to health insurance systems. Hormonal replacement therapy is effective in osteoporosis prevention, but concerns have been raised with regard to its safety. On the whole, the increase in life expectancy for postmenopausal women along with the need to improve their quality of life makes it necessary to develop specific and safe therapeutic strategies, alternative to hormonal replacement therapy, targeting both sarcopenia and osteoporosis progression. This review will examine the rationale and the effects of dietary protein, vitamin D and calcium supplementation combined with a specifically-designed exercise training prescription as a strategy to counteract these postmenopausal-associated disorders. Sarcopenia was firstly described at the end of the twentieth century by Rosenberg as a degenerative depletion in muscle mass  associatEven though there is still heterogeneity in diagnostic criteria and modalities to detect sarcopenia, the most used is the definition adopted by the European Working Group on Sarcopenia in Older People (EWGSOP) . The groAlthough it is challenging to distinguish among sarcopenia, frailty and cachexia, they do represent different conditions: frailty has been defined by Morley et al. as “a medical syndrome with multiple causes and contributors that is characterized by diminished strength, endurance and reduced physiologic function that increases an individual’s vulnerability for developing increased dependency and/or death,” of which sarcopenia can be an aspect ; cachexiThe loss of muscle mass begins substantially at the age of 50 and continues afterwards  with simSeveral studies highlighted an association between sarcopenia and osteoporosis, another age-related disease involving low bone mineral density (BMD), bone tissue frailty and risk of fractures . OsteopoMuscle-bone physiological interaction is increasingly reputed to be essential to prevent disease and disability in the elderly: in particular, Sjöblom et al. reported that women suffering from sarcopenia have more than a double higher risk of fracture and falls compared to those without the disease . Among mIn the elderly vitamin D deficiency often occurs and it is associated with sarcopenia, bone loss and disability. Vitamin D is highly interconnected with phosphate and calcium metabolism, as first demonstrated by Harrison and Harrison in 1961 . The 1,2On the whole, the increase in life expectancy for postmenopausal women along with the need to improve their quality of life makes it necessary to develop specific therapeutic strategies, in association with HRT or as an alternative to it. Here we discuss the effect of protein intake, vitamin D supplementation, physical activity and of their synergistic administration in maintaining musculoskeletal health in postmenopausal women.One of the most responsive pathways involved in musculoskeletal health is the Mammalian target of rapamycin (mTOR), involved in several anabolic processes in skeletal muscle . mTOR isIn women, the age-related decline of skeletal muscle mass and strength accelerates with the beginning of menopause. Oestrogen signalling of muscle satellite cell activation and proliferation is mediated via oestrogen receptor-alpha (ERα) placed on skeletal muscle and activates several signalling pathways including IGF-1 signalling, nitric oxide signalling or activation of the phosphor-inositide-3 kinase/protein kinase B (Akt) pathway which then act to positively influence muscle satellite cells and promote protein synthesis . Recent Accordingly, estradiol plays an important role in the morphological muscle status increasing translocation of the glucose transporter, GLUT-4 to the plasma membrane through Akt pathway. Indeed, it causes an increase of myogenin and myosin heavy chain levels, which are important in skeletal muscles remodelling ,43. EstrSeveral studies demonstrated an association between sarcopenia and osteoporosis, another age-related disease characterized by low BMD leading to bone tissue frailty and risk of fractures , with a Also, tendons, ligaments, cartilage and connective tissue can affect muscle bone cross-talk ; periostOestrogen-based HRT has an important role in maintaining and enhancing muscle mass and strength and also in protecting against muscle damage. The benefits of oestrogen for the skeletal muscle coupled with their additional positive actions on bone and metabolic health in older females provide further incentives for HRT use to enhance overall health in postmenopausal women. HRT is associated with an improved contractile function and power in 50–65-year-old women , while rThe risks associated with taking a pharmacological substitution therapy is much debated, but, in light of the most recent scientific acquisitions, menopause can be tackled by acquiring healthy habits that prevent the related disorders. Thanks to the better understanding of the causes, the ease of access to the diagnosis and the possibility of treatment before fractures occurrence today, a real prevention of both sarcopenia and osteoporosis and associated complications is possible. First of all, the fact is that muscle and bone health is a process that must develop throughout life in both males and females. Building a strong and healthy muscle-skeletal structure in childhood and adolescence can be the best defence. The further key steps that should be pursued at all ages for a successful prevention should consider: monitor a balanced diet rich in protein sources, calcium, magnesium and vitamin D that could interfere with anabolic mediators for both muscle and bone; practice exercise to enhance muscle strength, power output, neuromuscular activity and muscle mass; follow healthy lifestyles  and, when appropriate, perform tests to define bone mineral density and possibly undergo appropriate treatment.Given the strict association between loss of muscle  and bone mass  that accompany aging, physical activity and exercise represent effective preventive and therapeutic strategies able to slow down sarcopenia progression and prevent/delay the onset of and treat, osteoporosis. Indeed, exercise has beneficial effects on muscle mass, muscle strength and physical performance ,60,61, wLiterature put a strong emphasis on resistance training for all individuals with osteoporosis  and recoAged skeletal muscle possesses a reduced ability to respond to amino acid and insulin levels, leading to the concept of anabolic resistance, influenced by dietary protein digestion and amino acid absorption, plasma availability and hormonal response . Moreau Data from the National Health and Nutrition Examination Survey (NHANES) showed that, despite recommendations, daily protein intake decreases in the elderly and at least 8% of women consume an insufficient amount of protein . 35% of Increased availability of amino acids has positive effects on muscle anabolism  improvinThe best daily frequency for consuming protein, that is, single versus fractionated intakes, is still under debate. Indeed, some studies reported that daily protein should be consumed in a single meal, since a protein pulse feeding was more efficient than protein spread feeding in improving protein retention  and incrSeveral factors can influence postprandial MPS: in particular, muscle disuse as a consequence of sarcopenia or immobilization causes a decrease in basal metabolic rate and muscle strength  and dietAlongside total protein amount and within-day protein distribution, quality of protein and their sources should be considered  in termsMore recently, Zhu et al. demonstrated that in older postmenopausal well-nourished healthy women (70–80 years old) 30 g/day of extra protein did not improve the maintenance of muscle mass or physical function despite muscle deterioration in the upper limb. The authors attributed the lack of effects to the high habitual protein intake of women involved in this study, suggesting that protein intervention could be more effective in not well-nourished population. Furthermore, the intervention was not carried out in combination with resistance exercise, which has been demonstrated to improve protein effect . Daly etFigueiredo Braggion et al. compared the effects of diets rich in vegetable protein versus animal protein in ovariectomized old female rats (a condition that may only mimic human menopause) in association or not with resistance training. They demonstrated that animal protein diet combined with training promoted muscle remodelling  more efficiently compared to other conditions applied . More imMilk is a high-quality protein source, able of increasing muscle synthesis to a similar extent that whey  and beefBesides the effect of global amino acid availability, specific amino acids such as leucine, glutamine and arginine can play an important muscle health effect. Leucine  supplementation has been proposed as a strategy to counteract anabolic resistance in older muscle since it acts as a signalling molecule able to activate mTOR and thus protein synthesis . Also, XTaken together, the above evidence suggests that postmenopausal women need an adequate protein intake, in association with exercise  (80–90%), a precursor of cholesterol, after exposure to ultraviolet B light. This endogenous synthesis mainly depends on the intensity of solar radiation. Very limited number of foods contains vitamin D such as fatty fish  or mushrooms, whereas milk products and eggs contain only small amounts of vitamin D. Calcitriol can be produced both by dietary sources and endogenous vitamin D through two hydroxylation reactions. The diet provides about 10–20% of the daily requirement of vitamin D. 25-hydroxyvitamin D (25(OH)D), the precursor of calcitriol, is the major circulating form of vitamin D and is considered the best biomarker to assess the vitamin D status; it circulates bound to a specific plasma carrier protein, vitamin D binding protein, that also transports the calcitriol.The Institute of Medicine defines plasma concentration of 25(OH)D as adequate (25(OH)D concentrations >  50 nmol/L or > 20 ng/mL), insufficient (25(OH)D concentration between 30–50 nmol/L or 12–20 ng/mL), or as deficient (25(OH)D levels <  30 nmol/L or < 12 ng/mL). The committee stated that 50 nmol/L is the serum 25(OH)D level that covers the need of 97.5% of the population. Serum concentrations >125 nmol/L or > 50 ng/mL are associated with potential adverse effects .Serum 25(OH)D levels < 50 nmol/L are associated with increased bone turnover, bone loss and possibly mineralization defects and poorer outcomes for frailty, hip fracture and all-cause mortality ; furtherHigh levels of dietary calcium intake and/or calcium supplements can significantly improve bone mineral content and density in postmenopausal women, however, some studies suggest that calcium supplements alone may not be sufficient to reduce fracture risk and that additional vitamin D supplementation is required; calcium, in combination with vitamin D supplementation, reduces the risk of fragility fractures and increases the survival in the elderly ,127.Furthermore, an increased level of calcium intake during the period of childhood and adolescence can lead to a reduction in the risk of osteoporosis during old age and post menopause .Vitamin D has a pivotal role in the regulation and uptake of calcium in muscle cells, promoting protein synthesis and calcium and phosphate transport in muscle, which is important for muscle strength and contractile activity. Vitamin D appears to optimize the effect of dietary protein on skeletal muscle anabolism . Both diThe presence of nuclear VDRs in muscle tissue suggests that vitamin D acts on muscle via a genomic transcriptional effect. Mechanistically, it has been suggested that 1,25-dihydroxyvitamin D binds to the nuclear VDR in muscle resulting in de novo protein synthesis . Salles Furthermore, vitamin D signalling via VDR regulates gene transcription and activates further intracellular signalling pathways involved in calcium metabolism and it has been suggested to be involved in myoblast proliferation and differentiation . ProximaOsteoporosis and sarcopenia are two disorders affecting elderly people; their increasing incidence, due to the longer life expectancy in most western countries, might become an uncontrolled clinical and financial burden in the next few years. Early diagnosis, prevention and treatment of these disorders represent a very current but actually unmet, social and medical need. The evidence of profound interactions between bone and muscle causes a sort of negative resonance between the two tissues when they are simultaneously affected by osteoporosis and sarcopenia, respectively. Indeed, the coexistence of this twin condition in ageing leads to an accelerated worsening of the quality of life, poor clinical perspectives and high utilization of health resources. Due to the age- and/or gender-associated prevalence of sarcopenia and osteoporosis, postmenopausal women are potentially more prone to such a joint clinical situation. Nutritional and lifestyle factors may positively affect muscle and bone mass and function and have the advantage to be cheap and safe. To this regard, protein, vitamin D and calcium supplementation combined with a specifically-designed training protocol, emphasizing progressive RET, are capable of directly targeting some of the major physio-pathological causes of the twin condition progression and could simultaneously and coherently delay or revert the vicious cycle leading to the reciprocally-induced deterioration and wasting of osteoporotic bone and sarcopenic muscle .The medical and social relevance of strategies alternative to HRT targeting both sarcopenia and osteoporosis progression based on a female-specific rationale would be invaluable. To this regard, the development of controlled and selected protein and vitamin D supplementation regimens in combination with specifically-designed exercise training protocols may represent a cheaper and safer alternative to oestrogen replacement therapies.


As part of the monitoring and evaluation strategy for IDSR continuous improvement, data quality assessment (DQA) of the IDSR system to identify successes and gaps in the disease surveillance information system (DSIS) with the aim of ensuring data accuracy, reliability and credibility of generated data at all levels of the health system; and to inform an operational plan to address data quality needs for IDSR activities is required.stage 1: simple random sample (SRS) of five counties, stage 2: simple random sample of two districts and stage 3: simple random sample of three health facilities was employed during the study pilot assessment done in Montserrado County with Liberia institute of bio medical research (LIBR) inclusive. A total of thirty (30) facilities was targeted, twenty nine (29) of the facilities were successfully audited: one hospital, two health centers, twenty clinics and respondents included: health facility surveillance focal persons (HFSFP), zonal surveillance officers (ZSOs), district surveillance officers (DSOs) and County surveillance officers (CSOs).multi-stage cluster sampling that included the assessment revealed that data use is limited to risk communication and sensitization, no examples of use of data for prioritization or decision making at the subnational level. The findings indicated the following: 23% (7/29) of health facilities having dedicated phone for reporting, 20% (6/29) reported no cell phone network, 17% (5/29) reported daily access to internet, 56.6% (17/29) reported a consistent supply of electricity, and no facility reported access to functional laptop. It was also established that 40% of health facilities have experienced a stock out of laboratory specimens packaging supplies in the past year. About half of the surveyed health facilities delivered specimens through riders and were assisted by the DSOs. There was a large variety in the reported packaging process, with many staff unable to give clear processes. The findings during the exercise also indicated that 91% of health facility staff were mentored on data quality check and data management including the importance of the timeliness and completeness of reporting through supportive supervision and mentorship; 65% of the health facility assessed received supervision on IDSR core performance indicator; and 58% of the health facility officer in charge gave feedback to the community level.public health is a data-intensive field which needs high-quality data and authoritative information to support public health assessment, decision-making and to assure the health of communities. Data quality assessment is important for public health. In this review completeness, accuracy, and timeliness were the three most-assessed attributes. Quantitative data quality assessment primarily used descriptive surveys and data audits, while qualitative data quality assessment methods include primarily interviews, questionnaires administration, documentation reviews and field observations. We found that data-use and data-process have not been given adequate attention, although they were equally important factors which determine the quality of data. Other limitations of the previous studies were inconsistency in the definition of the attributes of data quality, failure to address data users’ concerns and a lack of triangulation of mixed methods for data quality assessment. The reliability and validity of the data quality assessment were rarely reported. These gaps suggest that in the future, data quality assessment for public health needs to consider equally the three dimensions of data quality, data use and data process. Measuring the perceptions of end users or consumers towards data quality will enrich our understanding of data quality issues. Data use is limited to risk communication and sensitization, no examples of use of data for prioritization or decision making at the sub national level. Liberia and other countries in the WHO African Region continue to be affected by inconsistent data at all levels of the surveillance system, which may affect the implementation of the IDSR in a negative manner. Public health data are used to monitor trends in the health and wellbeing of the community and of health determinants. Also, they are used to assess the risks of adverse health effects associated with certain determinants, and the positive effects associated with protective factors. The data informs the development of public health policy and the establishment of priorities for investment in interventions aimed at modifying health determinants. They are also used to monitor and evaluate the implementation, cost and outcomes of public health interventions, and to implement surveillance of emerging health issues . Thus, pThe data quality audit was conducted in five phases: phase one focused on the preparatory activities, phase two involved desk review of reported data, phase three activity was field assessment, during phase four, an action plan was developed, and phase five focused on the compilation of data, report writing, and results dissemination to stakeholders. This exercise was carried out from January 2-April 17, 2018  of five counties, stage 2: SRS of two districts and stage 3: SRS of three health facilities. Pilot assessment was done in Montserrado County with Liberia institute of bio medical research (LIBR) inclusive. A total of thirty (30) facilities was targeted, twenty-nine (29) of the facilities were successfully audited: one hospital, two (2) health centers, twenty-six (26) clinics and respondents included: health facility surveillance focal persons, ownal surveillance officers (ZSOs), district surveillance officers (DSOs) and County surveillance officers (CSOs) (s (CSOs) .Data quality assessment (DQA) tool: the WHO DQA tool was used for the assessment. The tool was piloted in Montserrado County. Techniques used for data collection were direct observation of data collection and management at all levels. At the health facility, the source of data (patients ledgers and surveillance ledgers) were reviewed, surveillance officers at that level were observed documenting the data or information, interviews and focused group discussions with health facility surveillance focal persons, ZSOs, DSOs and CSOs were conducted by the assessment team form NPHIL/MOH/WHO/ CDC/ John Hopkins University (JHU). Surveillance staff background and training history, competency, specimen collection procedures, case reporting procedures, data analysis, interpretation, and use, support Infrastructure, data Sources, validation of maternal deaths, acute bloody diarrhea, measles, and acute flaccid paralysis, IDSR weekly reporting form, health management information system, health facility registers & charts, identification of key areas for improvement, action items, supervision, mentorship, and feedback and perceptions, knowledge, and attitudes about surveillance.Key informants: these were the surveillance focal persons, district surveillance officers and County ourveillance officers. An interviewer-administered questionnaire was used to interview key informants to assess their knowledge on data quality and operations of the surveillance system. The field assessment was carried out by five (5) teams comprising of four (4) persons. One team was assigned to each county. Each team was made up of a NPHIL staff , a surveillance officer (County level) and a staff from supporting agencies such as WHO, CDC and JHU. Permission was sought from the MoH and NPHIL to carry out this study as part of strengthening public health surveillance in Liberia. Verbal or written consent was obtained from all interviewees and confidentiality was guaranteed, and the questionnaire for this data quality assessment was structured according to the levels of Liberia health care delivery system  was conducted in five selected counties to assess the quality of data generated and determine factors that influence the quality of surveillance data within the IDSR reporting system. A descriptive cross-sectional study was conducted in 30 health facilities A multi-stage cluster sampling technique was used. Five counties , were initially selected using simple random sampling. The districts under each county were classified as urban and rural. In each stratum, one health district was selected giving a total of ten (10) health districts. Within each health district three (3) health facilities were randomly sampled making a total of 30 health facilities (cilities .The findings indicated that 23% (7/29) reported a dedicated phone for the health facility, 20% (6/29) reported no cell phone network, 17% (5/29) reported daily access to internet, 56.6% (17/29) reported a consistent supply of electricity, no facility reported access to functional laptop and 70% (21/29) reported access to a motorbike for community visits . The finFor the data analysis and use: a checklist as per WHO guidelines for data quality audit was used to assess key indicators of quality surveillance data. A vicariate and bivariate analysis was conducted to summarize data collected using Epi Inform™ version Most health facilities reported using data to inform topics during the health talks. 100% of the DSOs assessed, correctly recalled the definition of zero reporting, case definition for measles, and case definition for maternal death and high numbers of disease are used for sensitization, specifically around measles and diarrhea 1 DSO did not correctly recall the epidemiologic week, and AFP case. Recall of diseases under surveillance was >80% for all conditions.Sound and reliable data quality assessment is vital to obtain the high data quality which enhances users’ confidence in public health and their performance. As Liberia monitors and evaluates the performance and progress of IDSR indicators, the need for data quality assessment in public health information system that store the performance-and-progress-related data needs to be routinely undertaken to ensure generation of credible, reliable and quality data. High quality data and effective data quality assessment are required for accurately evaluating the impact of public health interventions and measuring public health outcomes. Data use, and data collection process as the major dimensions of data quality, all need to be continuously assessed for overall data quality. Data quality audit “DQA” has been routinely conducted by MoH/NPHIL-Liberia as part of the IDSR implementation strategy to improve disease surveillance and the information generated helps to improve training, supervision, and reporting tools of the program across the country. Data are essential to public health. They represent and reflect public health practice. The broad application of data in IDSR for the evaluation of public health accountability and performance has raised the awareness of NPHIL, MoH, WHO and public health agencies of data quality, and of methods and approaches for its assessment .We systematically reviewed the current status of quality assessment for each of the three dimensions of data quality: data, data collection process and data use. The results suggest existence of data capture tools at all levels of health care system with most assessed indicators above 80%. Our findings based on the proposed conceptual framework of data quality assessment for public health identified gaps in reporting aggregated IDSR data not harmonised with DHIS2, and limited data use for decision making. Data quality is influenced by technical, organizational, behavioural and environmental factors. It covers large information systems contexts, specific knowledge and multi-disciplinary techniques. Data quality audit is frequently done as a component of the quality or effectiveness or performance of the IDSR. However, data quality assessment hidden within other scopes may lead to ignorance of data management and thereby the unawareness of data quality problems enduring in public health practice. Data quality needs to be positioned at the forefront of IDSR as a distinct area that deserves specific scientific research and management investment.While this review provides a detailed overview of data quality assessment issues, there are some limitations in its coverage, constrained by the access to the databases and the breadth of public health information systems making it challenging to conduct systematic comparison among studies. The importance of systematic, scientific data quality assessment needs to be highlighted. All three dimensions of data quality, data use and data collection process, need to be systematically evaluated. The quality of data use and data collection process has not received adequate attention. This lack of recognition of data use and data collection process might reflect a lack of consensus on the dimensions of data quality. Further development in methods to assess data collection process and data use is required. Effort should also be directed towards clear conceptualisation of the definitions of the relevant terms that are commonly used to describe and measure data quality, such as the dimensions and attributes of data quality. Data quality assessment was mixed methods  to assess data from multiple sources  and used at health facility, district and county levels. The validity of a study would be doubtful if the quality of data could not be verified in the field, especially when the data from data capture tools are varied with data submitted to national level has no errors. This was limited by the coverage to 5 out of 15 counties and to the databases of IDSR, DHIS2 and data capture tools at health facility, district and county levels. Further research could develop consistent data quality definitions, attributes, quality of data use and the quality of data collection process. Data-use and data-process have not been given adequate attention at health facility, district and county levels, although they were equally important factors which determine the quality of data.Recommendations: conduct regular data harmonization/audit at subnational level to ensure that health workers are knowledgeable on the importance of quality and reliable data. Capacity building for health workers at sub national level in data management. Ensure the institutionalize data management training in pre-service and academic institutions, on-going in-service refresher trainings in data analysis for public health actions. Establish an effective system to improve data harmonization at the subnational level.Public health is a data-intensive field which needs high-quality data and authoritative information to support public health assessment, decision-making and to assure the health of communities. Data quality assessment is important for public health. In this review Completeness, accuracy, and timeliness were the three most-assessed attributes. Quantitative data quality assessment primarily used descriptive surveys and data audits, while qualitative data quality assessment methods include primarily interview, questionnaire administration, documentation review and field observation. We found that data-use and data-process have not been given adequate attention, although they were equally important factors which determine the quality of data. Other limitations of the previous studies were inconsistency in the definition of the attributes of data quality, failure to address data users’ concerns and a lack of triangulation of mixed methods for data quality assessment. The reliability and validity of the data quality assessment were rarely reported. These gaps suggest that in the future, data quality assessment for public health needs to consider equally the three dimensions of data quality, data, data use and data process. Measuring the perceptions of end users or consumers towards data quality will enrich our understanding of data quality issues Data use is limited to risk communication and sensitization, no examples of use of data for prioritization or decision making.Data quality audits lead to improvement in over reporting and under reporting which compromise informed decisions, integrity of generated data, quality assurance standards and compliance levels;Public health is a data-intensive field which requires high-quality data to support public health decision-making;Improving data quality requires good data capturing tools that are capable of analysing the quality of data generated based on data quality audits.Forty percent (40%) of surveillance officers at health facility level lack training in data management;Undefined data management strategy and quality level makes data generated overwhelming and less useful in decision making;Regular data quality audit is necessary to understand the actual status of data quality and integrity issues in the health care delivery system and addresses data quality challenges aimed at improving data consistency, reliability and informed decisions.The authors declare no competing interest.