Global strategy for women’s, children’s and adolescents’ health (2016–2030) provides a roadmap for ending preventable deaths of women, children and adolescents by 2030 and helping them achieve their potential for and rights to health and well-being in all settings.The ,Global strategy for women’s and children’s health (2010–2015),,Like the SDGs, the global strategy is universal in scope and multisectoral in action, aiming for transformative change across numerous challenging areas for health and sustainable development .1 The stBox 1Survive: end preventable mortality;Thrive: promote health and well-being; andTransform: expand enabling environments.People: individual potential and community engagement;Political effectiveness: country leadership, financing, accountability;Programmes: health system, multisector, humanitarian, research and innovation;Partnerships: Every Woman Every Child Partnerships, including the Global Financing Facility, the United Nations and multilateral H6 partnership, Unified Accountability Framework and Independent Accountability Panel, Innovation Marketplace and other national, regional and global partnerships; andPrinciples: country-led, universal, sustainable, human-rights based, equity-driven, gender-responsive, evidence-informed, partnership-driven, people-centred, community-owned, accountable, aligned with development effectiveness and humanitarian norms.,,Evidence shows that progress is required across a set of overlapping and mutually reinforcing areas to improve the health, dignity and well-being of women, children and adolescents.,–,,Evidence indicates that countries can accelerate progress in health and sustainable development through integrated action within the health sector and across social, economic and environmental sectors.The actions and approaches required to achieve the objectives of the global strategy (2016–2030)The global strategy (2016–2030) emphasizes the importance of measures to help all women, children and adolescents to realize their rights and full potential for health and well-being. These measures include policies and programmes for early childhood development and adolescent health. Removing barriers to enjoyment of rights– such as those to gender-equality and women’s socioeconomic and political participation are also important measures.Evidence shows that early childhood development programmes have significant long-term health and socioeconomic advantages. Parenting resources for early childhood development, school-community outreach and health services have measureable physical, intellectual and socioeconomic benefits for children, their families and communities. Such actions can reduce health, special schooling and criminal justice expenditures.Healthy, educated adolescents can better realize their potential, contribute to the demographic dividend and economic growth, as seen in east Asia in the 1980s and 1990s.,Women’s social, political and economic participation is associated with better health outcomes for women and children.,,,Leadership at all levels of society is a proven prerequisite for progress.Robust data and analysis are essential to enable accountability through a cycle of monitoring, independent review and action to ensure that programmes and policies are achieving their desired objectives. For example, in Mozambique a coalition of partners invested in the country’s civil registration and vital statistics system, increasing registered deaths by 18% from 2012 to 2014 and enabling routine reporting of causes of death by sex and age for the first time since 1975 .,To strengthen accountability, at least 50 countries with a high burden of maternal and child mortality had regular national health sector review processes that met basic accountability criteria in 2015, and another 36 countries had adopted the good governance for medicines approach to battle corruption.Quality programmes in health and other sectors, and for research and innovation, can catalyse change, even in humanitarian and fragile settings. While resilient health systems and universal coverage of quality care are gold standards for women’s, children’s and adolescents’ health, catastrophic events can swiftly undo hard-won health gains, particularly where existing health systems are weak. For example, during the 2013–2016 Ebola disease outbreak in Liberia, skilled birth attendance fell from 52% to 38%, vaccination rates dropped and 64% of health facilities were not operational.Experience shows that quality care is possible even under extreme circumstances. In Jordan, humanitarian and development partners have collaborated to give all residents of Za’atari refugee camp access to maternal and child health centres, while additional health centres serve Syrian refugees who are not living in camps.,,While the health sector remains central for people’s health, there is evidence that in low- and middle-income countries about 50% of gains in women’s and children’s health since 1990 have resulted from progress in non-health sectors.Evidence shows that knowledge and innovation are at least as important as economic resources in improving health and well-being and driving development. Research to help countries understand and overcome barriers is required in areas such as: policy, implementation and operational research; clinical research and systematic evidence reviews; disaster risk reduction and preparedness; social, behavioural, anthropological and community research; and political and social sciences.Multistakeholder and cross-sector partnerships are critical drivers of change. In the United Republic of Tanzania, the White Ribbon Alliance for Safe Motherhood united civil society members, health professionals, academics, donors and United Nations (UN) partners in a successful three-year campaign to improve access to comprehensive emergency obstetric and newborn care at health centres.Effective global partnerships can catalyse and support country efforts. For example, the Every Woman Every Child movement attracted more than US$60 billion dollars to women’s and children’s health between 2010 and 2015, with commitments from over 300 partners.The movement has spurred partnership mechanisms to support country-led implementation of the global strategy (2016–2030) – including the Global Financing Facility in support of Every Woman Every Child, the Innovation Marketplace, Unified Accountability Framework and the UN system’s health agencies’ H6 partnership.The global strategy (2016–2030) recognizes that human rights and other fundamental development principles – such as equity, community ownership and development effectiveness – are drivers of transformative change.In Peru, principles of equity underpinned a programme of poverty mapping to identify and prioritize reaching poor, rural and indigenous populations with social protection programmes and culturally appropriate, affordable care.The global strategy (2016–2030) provides knowledge for integrated actions both within the health sector and with other sectors, based on country experience and current evidence. With its accompanying operational framework, the strategy serves as a roadmap for collective action to advance the health and well-being of women, children and adolescents, which will be central to achieving the SDGs.


Although the regionalization of public health systems has been well documented in the case of emergency preparedness, there is little literature on the application of regional approaches to other aspects of public health. From 2011 through 2014 the Washington State Department of Health implemented a Community Transformation Grant to support community-level policy and systems changes to decrease chronic disease risk factors and increase access to clinical preventive services. The Department of Health implemented the grant through a regional model, grouping 32 of the state’s 35 local health jurisdictions into 5 regions. Our process evaluation identifies the challenges and facilitators to Community Transformation Grant planning and implementation. We conducted 34 key informant interviews with people directly involved in the implementation of the Community Transformation Grant. We interviewed state and local partners, including representatives from each region, the Department of Health, external consultants, and regional partners. We collected data from October 2013 through July 2014.Challenges for planning, building, and implementing a regional model for chronic disease prevention included stakeholder buy-in, regional geography, and communication; facilitators included shared regional history and infrastructure, strong leadership, collaborative relationships, shared vision and goals, sufficient funding, and direct technical assistance and training.Lessons learned in Washington State provide a foundation for other states interested in using a regional approach to reduce chronic disease risk. Policy and systems changes require adequate time, funding, and staffing. States and funders should work closely with local leaders to address these challenges and facilitators. Local health jurisdictions (LHJs) across the United States began exploring the regionalization of public health work though intrastate governance systems in the 1970s . Many USPublic health experts believe regional work can support increased efficacy and efficiency because larger public health delivery systems generally maintain stronger performance measures . ProvidiThe potential for cost savings through regional public health models has prompted increased use; some states have explored the benefits of also regionalizing systems for chronic disease management and prevention ,6. SinceThe Future of the Public’s Health in the 21st Century identified the adoption of “healthy” policies as a necessary strategy for governments and regional partners to improve population health  a CTG to improve community health through policy, environment, and systems changes. The CTG focused on “expanding efforts in tobacco-free living, active living and healthy eating, quality clinical and other preventive services, and healthy and safe physical environments” . ExampleWashington State has a decentralized public health system, with 39 counties divided into 35 distinct LHJs. A decentralized system affords LHJs substantial influence and control over the provision of local public health services; however, it requires a high level of administrative funding to support each department because of overhead costs and necessary programs and services.Growing fiscal constraints and challenges in maintaining equitable public health services across the state prompted WA DOH to implement the CTG through a regional model. WA DOH’s long-term vision was to use this regional model to develop a comprehensive statewide chronic disease prevention system, eventually funneling non-CTG funding through regions as well.WA DOH designated 5 regions and 11 priority counties in their CTG proposal to CDC ; particiWe conducted a process evaluation of CTG implementation in Washington to better understand the challenges and facilitators to implementing a statewide regional model to reduce chronic disease risk through policy and systems changes. WA DOH planned to use the evaluation results to make midcourse improvements. However, although CDC awarded the CTG as a 5-year grant, the federal government cut funding after year 3. Lessons learned from the implementation of the CTG in Washington State can support both Washington and other states in planning, building, and implementing regional models to reduce chronic disease through policy and systems changes. This evaluation also contributes to the literature on the implementation of regional public health work beyond emergency preparedness .From October 2013 to July 2014, we conducted a qualitative process evaluation of Washington State’s CTG implementation. Our data collection methods were document review  and 34 semi-structured key informant interviews. The consolidated criteria for reporting qualitative research guided our methodology .Direct technical assistance and training. Technical assistance provided by independent external consultants was available to help regions implement program-related evidence-based practices, conceptualize policy and systems change work in their region, and build regional and cross-jurisdictional collaboration. Participants in regions that received a high level of technical assistance felt it provided valuable expertise and additional capacity to advance policy and systems changes. Furthermore, several participants felt that direct technical assistance could play a key role in supporting regions to develop sustainability plans and secure long-term funding.In this process evaluation we identified specific challenges and facilitators to building and implementing a regional public health model to reduce chronic disease risk factors through policy, environment, and systems changes. Lessons learned in Washington State may help other states plan, build, and implement similar regional models.Many of the challenges and facilitators we identified are similar to those described in literature on cross-jurisdictional emergency preparedness planning. However, achieving policy and systems changes differs from other cross-jurisdictional efforts given its long-term nature and relative newness to public health –19. CommPolicy and systems change work can be contentious. Participants found engaging stakeholders and obtaining buy-in from local leaders and regional partners to be an arduous process. This underscores the importance of developing regional models with the intention to maintain these relationships once established. Participants in this evaluation said that policy and systems changes require time, ongoing and sustainable funding, and the flexibility to change course if needed.Effective implementation of regional models requires that funders and administrators engage local partners early and often. Before determining geographic regions and regional work plans, it is important that funders and administrators consider historical relationships, political tensions within and across regions, and objections to regional work. Obtaining buy-in and assessing local environments is time-intensive. Funders can support the process by providing sufficient time for local engagement during the grant proposal–writing process, at the start of the funding period, or both.Stable, ongoing, and flexible funding is critical to support regionalized policy and systems change work ,9. EffecAs a process evaluation, we did not evaluate CTG outcomes across regions or the health effects of the policy and systems changes implemented in Washington State through CTG. Rather, this research is limited to the process of implementation and the factors that affected regions’ abilities to implement the work. Although our findings will not provide midterm feedback for WA DOH because of the early termination of CTG funding, they remain meaningful given Washington’s intent, and the incentives, to continue regional efforts.These results are not uniformly generalizable. We need future research and ongoing evaluation to develop an evidence base for the efficacy of regional public health models as a strategy to prevent and reduce chronic disease. We also need further research to understand the financial implications and potential cost savings of resource-sharing across local public health jurisdictions.


In recent years, issues in medical business ethics (MBE), such as conflicts of interest (COI), Medicare fraud and abuse, and the structure and functioning of reimbursement systems, have received significant attention from the media and professional associations in the United States. As a result of highly publicized instances of financial interests altering physician decision-making, major professional organizations and government bodies have produced reports and guidelines to encourage self-regulation and impose rules to limit physician relationships with for-profit entities. Nevertheless, no published curricula exist in the area of MBE. This study aimed to establish a baseline level of knowledge and the educational goals medical students and residents prioritize in the area of MBE.732 medical students and 380 residents at two academic medical centers in the state of Missouri, USA, completed a brief survey indicating their awareness of major MBE guidance documents, knowledge of key MBE research, beliefs about the goals of an education in MBE, and the areas of MBE they were most interested in learning more about.Medical students and residents had little awareness of recent and major reports on MBE topics, and had minimal knowledge of basic MBE facts. Residents scored statistically better than medical students in both of these areas. Medical students and residents were in close agreement regarding the goals of an MBE curriculum. Both groups showed significant interest in learning more about MBE topics with an emphasis on background topics such as “the business aspects of medicine” and “health care delivery systems”.The content of major reports by professional associations and expert bodies has not trickled down to medical students and residents, yet both groups are interested in learning more about MBE topics. Our survey suggests potentially beneficial ways to frame and embed MBE topics into the larger framework of medical education. In the market context of medicine in the United States, issues in medical business ethics (MBE), such as conflicts of interest (COI), Medicare fraud and abuse, and the structure and functioning of reimbursement systems, affect the integrity of medical practice and research. Substantial data indicate that self-serving bias subconsciously influences the way physicians weigh information and make decisions when financial incentives exist . FinanciThe Institute of Medicine (IOM) , the AssAttitudes toward industry are formed early in medical training , suggestFurthermore, although there are no data to indicate graduating residents’ views, the majority of graduating medical students believe current instruction and the exposure they have in medical school to health policy and economics has poorly prepared them for entrance into the US healthcare system . KnowledThe AMSA PharmFree Scorecard Methodology rates academic medical centers on the quality of their policies and practices regarding conflicts of interest, including the provision of an adequate curriculum for medical students on conflicts of interest. They specifically examine whether “Students are trained to understand institutional conflict-of-interest policies and recognize how industry promotion can influence clinical judgment ”. While The Bander Center for Medical Business Ethics at Saint Louis University (Bander Center), with whom the four authors are affiliated, has established the goal of publishing a freely available, online case-based curriculum in this area. This paper reports on a preliminary step in that process: Surveying medical students and residents to establish needs, interests, and priorities in the area of MBE.In January and February 2013, a brief, confidential survey was emailed to medical students and residents at Saint Louis University (SLU) and Washington University (WU) in Saint Louis, Missouri. Among those invited, 720 were medical students at SLU, 576 were medical students at WU (n = 1296), 617 were residents at SLU, and 562 were residents at WU (n = 1179) for a total of 2475. These medical schools incorporate both scheduled and elective courses in healthcare ethics and health policy as part of the required medical doctorate curricula; formal ethics instruction at both institutions occurs primarily during the preclinical years (MS1 and MS2). Residents at these institutions have less formalized training in ethics that may include lectures and ethics continuing medical education (CME). The 2013 AMSA Scorecard on “Conflicts of Interest Policies in Academic Medical Centers” graded the policies at WU with an “A” and policies at SLU with a “B”.A nine-item questionnaire was distributed using Qualtrics, a web-based survey software system. Invitations were sent over three weeks. Following the initial invitation, reminder emails were sent after the end of week one and week two to individuals who had not yet replied. As an incentive to complete the survey, we offered participants at each institution the chance to win an iPad Mini or one of two $50 gift cards; a total of six prizes were awarded using a lottery method.Participants were asked to select their affiliated academic medical center and their level of medical training. They were asked how familiar they were with four major guidance documents in the area of MBE: The Institute of Medicine (IOM) report entitled “Conflict of Interest in Medical Research, Education, and Practice” ; The OffThe next four multiple-choice questions tested participants’ knowledge of key research on MBE: the prevalence of physician relationships with medical industry , the natThe final two questions captured medical students’ and residents’ beliefs about the goals of an education in MBE, and the areas of MBE they were most interested in learning more about.This study was approved by the Institutional Review Board (IRB) at Saint Louis University.Survey data were analyzed using the Statistical Package for the Social Sciences (SPSS). Statistical analysis focused on descriptive statistics and the comparison of medical students (MS) and post-graduate residents (PG) using Chi square.The survey response rate was 45% (n = 1112). Respondents were evenly split between institutions: 553 from SLU (50%) and 559 from WU (50%). Respondents included 732 medical students (65%)—MS1 (16%), MS2 (16%), MS3 (12%), MS4 (13%), MD/PhD (8%)—and 380 residents (34%)—PGY1 (6%), PGY2 (7%), PGY3 (6%), PGY4 (5%), and PGY5 (4%), and PGY > 5 (6%).Tables Overall, participants had little awareness of recent, major reports addressing MBE topics .Educational programs should be developed to raise the awareness among students, trainees, and faculty of challenges to professionalism presented by certain interactions with industry and to provide opportunities that help them build critical evaluation skills that reinforce high individual standards, norms, and behaviors. P. 11.In contrast to the basic MBE awareness and knowledge questions, medical students and residents were in close agreement on what they believed the goals of an MBE curriculum should be  than the related, more overtly ethical issues. But it also makes excellent sense from the perspective of ethics pedagogy. Combining the business aspects of medical practice with related ethical issues situates ethical theory in real-world dilemmas and reinforces the idea that ethics is not separate from medical professionalism, but is an essential dimension of it , 32.http://www.slu.edu/bander-center-home.All authors are affiliated with the Bander Center for Medical Business Ethics at Saint Louis University whose mission is to promote ethical business practices in medical care and research through the development of training and investigation opportunities for medical students, residents and physicians in practice. Information on the Center is available at:


In the field of HIV prevention, there is renewed interest in operations research (OR) within an implementation science framework. The ultimate goal of such studies is to generate new knowledge that can inform local programmes and policies, thus improving access, quality, efficiency and effectiveness. Using four case studies from the USAID-funded Research to Prevention (R2P) project, we highlight the strategic use of OR and the impact it can have on shaping the focus and content of HIV prevention programming across geographic and epidemic settings and populations. These case studies, which include experiences from several sub-Saharan African countries and the Caribbean, emphasize four unique ways that R2P projects utilized OR to stimulate change in a given context, including: (1) translating findings from clinical trials to real-world settings; (2) adapting promising structural interventions to a new context; (3) tailoring effective interventions to underserved populations; and (4) prioritizing key populations within a national response to HIV. Carefully crafted OR can bridge the common gap that exists between research-generated knowledge and field-based practice, lead to substantial, real-world changes in national policies and programmes, and strengthen local organizations and the use of data to be more responsive to a given topic or population, ultimately supporting a locally tailored HIV response. Although not a new concept, operations research (OR) is an area of renewed interest to public health policymakers and programme planners . OR apprOR has been defined as a continuous process with five basic steps: (1) problem identification and diagnosis; (2) strategy selection; (3) strategy testing and evaluation; (4) information dissemination; and (5) information utilization. The goal of OR is generally understood as generating evidence that can assist to increase the efficiency, effectiveness and quality of services delivered by providers, as well as the availability, accessibility and acceptability of services for users  , 9. MoreThe growing interest in OR has been stimulated in part by recent biomedical advances in the field of HIV prevention and the increased emphasis on combination HIV prevention approaches . For exaAlthough many key OR questions have global relevance, ultimately, OR seeks to improve HIV outcomes at the local level. Previous work has identified the central role of context in OR, including the sociocultural, politico-legal and economic aspects of a setting, as well as specifics of a given health system and, in the case of HIV, dynamics of the local epidemic . To effeResearch to Prevention (R2P) was a USAID-funded task order conducted between 2008 and 2014 under the broader Project SEARCH  OR umbrella. R2P aimed to identify critical knowledge gaps and inform programme strategies for effective HIV prevention including improving the quality and coverage of prevention interventions in countries most affected by the epidemic, particularly sub-Saharan Africa. R2P had three key objectives: (1) to conduct OR in the area of HIV prevention; (2) to promote dissemination and utilization of data generated in the OR process; and (3) to build the capacity of local researchers and governmental and non-governmental institutions to conduct and use research findings.R2P conducted approximately 30 HIV prevention OR activities across 18 countries. In each of its field-based projects, collaboration with local research partners and engagement with government institutions was prioritized to conceptualize and implement a given activity and for capacity building. As a result, findings from R2P studies contributed to the addressing challenges that were relevant to the global OR agenda but were equally resonant and appropriate for the local context. Although R2P projects sometimes focused on a specific previously established biomedical, behavioural or structural intervention strategy, the research was situated in the socio-political context of a given setting.Here, we highlight examples of R2P OR projects across a variety of geographic and epidemic settings and population groups. Through each of the four case studies presented, we demonstrate how context-specific OR questions implemented collaboratively can lead to the prioritization and improvement of local HIV prevention programmes and policies. These cases emphasize several ways that OR can be strategically used to shape better HIV prevention decision making and outcomes, including: (1) translating findings from clinical trials to real-world settings; (2) adapting promising structural interventions to a new context; (3) tailoring effective interventions to underserved populations; and (4) prioritizing key populations within a national response to HIV, extending the manner in which we understand the role and utility of OR.Three randomized controlled trials previously demonstrated the efficacy of VMMC in reducing HIV acquisition risk among men –19. As aResults from SYMMACS showed that safe, high-quality VMMC can be implemented and sustained at scale, although quality was found to decline in areas where the number of new VMMC sites increased rapidly , 22. InfThe SYMMACS study team engaged in intensive data dissemination efforts in each study country and globally to extend the reach and utilization of the findings. This included conducting data utilization workshops, presenting findings to policymakers and collaborating with local investigators to publish results in peer-reviewed journals. Notably, SYMMACS results contributed to a change in government policy in Zimbabwe, which began allowing task shifting of VMMC procedures from doctors to nurses as of January 2014 . ElementThe high burden of HIV and sexually transmitted infections (STIs) in South Africa, especially among young people in disadvantaged urban settings, has led to increased interest in interventions that address the underlying structural drivers of the epidemic. Cash transfer interventions that provide monetary incentives to participants aim to address the socioeconomic context of HIV infection such as poverty . To dateAt six-month follow-up, the CHANGE study found that the clinic condition arm demonstrated a significant impact on health behaviour, with three times more clinic visits occurring in this group compared to other study arms . This fiAbriendo Puertas or “Opening Doors.” Abriendo Puertas was implemented collaboratively by local research, non-governmental organizations (NGO) and community partners, including a sex-worker led group. The intervention sought to address HIV and sex-work-related stigma and discrimination experienced by FSW living with HIV in multiple spheres of their lives including their sexual relationships, work, HIV clinics and communities [Female sex workers (FSW) have a significantly higher burden of HIV infection than adult women in the general population across settings . Yet, femunities . The appAbriendo Puertas intervention showed statistically significant improvements in consistent condom use with all sexual partners in the last month [After 10 months, women in the st month . Engagemst month , 37.Planning an effective national HIV response requires knowing the local epidemiology of HIV and the social and institutional factors that may affect the success of different intervention strategies. In Swaziland, key populations such as MSM and FSW had never been the focus of rigorous behavioural and biological surveillance prior to this R2P project, although these populations were known to be at heightened risk of HIV in other settings, even in generalized HIV epidemics , 38. TheFindings from the study enabled the Swaziland Ministry of Health to better focus their HIV response to their local epidemic and social, cultural and institutional context. For example, fear of stigma, violence and harassment from police and healthcare institutions were identified as barriers to uptake of HIV services, so current interventions include key populations sensitivity training with the Royal Swazi Police, adaptations to make clinics friendlier to key populations and community dialogues between MSM, FSW and healthcare providers . In addiThese diverse case studies from R2P projects highlight how OR can be used to shape HIV prevention policy and programmes. These studies spanned a variety of uses of OR, including translating global clinical trial findings to “real world” settings, adapting promising interventions in new contexts, tailoring the implementation of interventions to increase uptake among underserved groups and using data to prioritize the inclusion of specific groups within a national HIV response. The cases also highlight the range of OR questions, study designs and methods that can be used to address implementation challenges across different HIV prevention interventions, geographic and epidemic settings, and population groups. The examples emphasize the importance of collaboratively crafting strategic, context-specific OR to address the complex pathways of HIV risk and service uptake in different settings.Abriendo Puertas showed how formative research findings can be an important component of OR and used to tailor a multilevel intervention model for a specific population. Finally, the R2P project, with key populations in Swaziland, provided data that helped broaden the scope of a national HIV response while also empowering community members to take an active role. Advocating for policy change is one of the primary purposes of OR [The SYMMACS study showed how a key finding from randomized controlled trials was translated into real-world programming, and how OR can help document this transition, assess whether quality and efficiency of services are maintained during national scale-up in different countries and inform policy decisions for national programmes. This is exactly the “know–do” gap that OR is designed to fill. The CHANGE study demonstrated how OR can be used to adapt promising interventions in a new context, providing policymakers and programme planners with important information about how social, economic and structural differences may shape the pathways through which cash transfers affect HIV-related risk and service use behaviours among at risk youth in urban, resource-poor settings. es of OR , and OR es of OR . FurtherAbriendo Puertas), assessing the feasibility of interventions to inform ongoing policy debates (such as the CHANGE study) and providing information to inform local HIV programming and investment decisions (such as current programming for key populations in Swaziland). These case studies also show how OR can directly affect local policies in a governmental health system, such as Zimbabwe's new national policy to allow nurses to provide VMMC or Swaziland's decision to consult key populations when developing national proposals concerning HIV prevention, care and treatment [At the local level, each of the four R2P case studies shows how OR can be an integral component of informing policies and programmes (such as VMMC programmes), developing tailored programmes (such as reatment , 51. FinAbriendo Puertas could be used to identify and tailor feasible and empowering interventions for sex worker populations in different contexts.Although R2P OR studies generated knowledge that had local impact, the studies also had global relevance. The findings from SYMMACS will be used to inform the scale-up of VMMC services in other high-priority countries in sub-Saharan Africa, and the findings from the CHANGE study will be added to the currently limited global evidence base on the pathways through which cash transfers work to change behaviour and the intended and unintended consequences of an economic intervention in an urban, disadvantaged setting that targeted both females and males. Furthermore, models used for the OR in R2P can serve as a template for other work in OR. For example, as countries increasingly recognize the importance of having reliable data on key populations, the idea of using data to advocate for including underserved populations in the national HIV response could be replicated elsewhere. The methodologies used in R2P can be replicated as well. For example, the formative work used to design status quo thinking that has, to date, not adequately advanced the field of HIV prevention to appropriately tailor effective interventions to diverse contexts. For example, better aligning HIV prevention interventions with socio-cultural and political contexts may be critical to narrowing the translational gap to effective prevention programmes [Globally, the HIV response is currently characterized by a period of transitions to increasingly country-led initiatives and calls for increased programme efficiencies . In the ogrammes . AchieviWe see several opportunities for improving the OR agenda in the coming decade. First, there is a need to better integrate routine monitoring and evaluation with OR, linking routine daily assessment of inputs and outputs with OR questions of efficiency and effectiveness , 57. SecFinally, as PEPFAR moves towards more sustainable programmes and HIV epidemic control by targeting geographic areas and populations most at need with evidence-based, high-impact interventions , there wWe present four case studies from the USAID-funded R2P project demonstrating how the strategic use of OR can make specific impacts at multiple levels, including how it can lead to substantial changes in local programmes, national policies and global agendas, and how it can have an impact on the development of organizations and sustainable responses, tailoring the content of interventions for local contexts and population groups. Together, these examples highlight how we can contextualize a global OR and implementation science agenda, bring studies and their findings into national dialogues and policy debates, and partner effectively with local groups to make meaningful social change, strengthen the HIV response and positively have an impact on the people most affected by HIV.


Photoacoustic imaging (PAI) and thermoacoustic imaging (TAI) are two emerging biomedical imaging techniques that both utilize ultrasonic signals as an information carrier. Unique advantages of PAI and TAI are their abilities to provide high resolution functional information such as hemoglobin and blood oxygenation and tissue dielectric properties relevant to physiology and pathology. These two methods, however, may have a limited detection depth and lack of endogenous contrast. An exogenous contrast agent is often needed to effectively resolve these problems. Such agents are able to greatly enhance the imaging contrast and potentially break through the imaging depth limit. Furthermore, a receptor-targeted contrast agent could trace the molecular and cellular biological processes in tissues. Thus, photoacoustic and thermoacoustic molecular imaging can be outstanding tools for early diagnosis, precise lesion localization, and molecular typing of various diseases. The agents also could be used for therapy in conjugation with drugs or in photothermal therapy, where it functions as an enhancer for the integration of diagnosis and therapy. In this article, we present a detailed review about various exogenous contrast agents for photoacoustic and thermoacoustic molecular imaging. In addition, challenges and future directions of photoacoustic and thermoacoustic molecular imaging in the field of translational medicine are also discussed. Photoacoustic imaging (PAI) is a burgeoning biomedical structural and functional imaging technique which utilizes ultrasonic signals as an information carrier that captures information about optical absorption property relevant physiology and pathology inside tissues. The basic process of the PAI excitation source is summarized below: 1) the tissue absorbs light energy after being irradiated by visible light or near-infrared light; 2) the absorber produces adiabatic expansion that induces photoacoustic signals . Be. Beet alet al., have reported the ability of silica-coated gold nanorods to provide a stable photoacoustic signal, which implies good imaging capabilities. These nanorods thus make silica-coated gold nanorods a promising imaging and therapeutic nanoagent for photoacoustic imaging and image-guided photothermal therapy . Fi. Fiet aloncology .3O4 magnetic nanoparticles comprise another type of agents. They are almost spherical with diameters ranging from 30–50 nm. Qin, et al., investigated the feasibility of using this nanoparticle as a contrast agent in thermoacoustic tomography (TAT) for hepatocellular carcinoma ex vivo detection [2[Gd(DTPA)] is one such paramagnetic ionic compound with seven unpaired electrons in the 4f orbital of the Gd3+ ion. The charged ions and unpaired electrons can interact with a microwave field and transform the absorbed microwave energy into heat. Qin, et al., verified the enhanced effect of NMG2[Gd(DTPA)] for thermoacoustic CT in vitro and in vivo experiments. They demonstrated that this contrast agent can increase the ionic conductivity and microwave absorption coefficient of tumors, thus making the boundary between tumor and normal tissue more obvious in TAI , which is made of superparamagnetic nanoparticles conjugated to folic acid (FA). These nanoparticles can then bind specifically to the surface of the folate receptor, a tumor marker. Nie, et al., have used a 6 GHz TAT system to successfully investigate that intravenous administration of the targeted nanoparticles to mice bearing tumors showed a five-fold greater thermoacoustic signal and a much longer elimination time than that of nontargeted nanoparticles.This portrays Fe3O4/polyaniline (PANI)’s potential for its use in targeted and guided cancer thermal therapy  agents should be of excellent water solubility, or they will be treated as foreign objects and rejected by the surrounding tissue; (4) they should be of proper biological compatibility and low toxicity in order to not cause adverse reactions to the tissues—the most major being damage to the endothelium, vascular system, blood-brain barrier (BBB), kidneys, and so on; (5) contrast agent should have a tendency to bind molecular probes , drugs or another contrast agent. They should have good surface modification and be able to effectively target specific receptors in target cells or tissues; (6) have a high stability, long half-life, and full dissolution in vivo in order to make them meet clinical requirements; (7) they should possess very good dispersibility in order to distribute evenly in the imaging region; (8) photoacoustic contrast agents should have a high light-to-ultrasound conversion efficiency, while thermoacoustic contrast agents need a high microwave-to-ultrasound conversion efficiency. Contrast agents need to be prepared and used discreetly in accordance with the provisions of the Food and Drug Administration (FDA).Effective photoacoustic or thermoacoustic contrast agents should significantly increase contrasts, effectively improve imaging depths or accurately provide molecular specific information. It is therefore prudent to follow these principles when choosing contrast agents: (1) photoacoustic or thermoacoustic contrast agents should be easily prepared and produced for a low cost due to future clinical applications; (2) the size of contrast agents has a significant impact on their distribution and drug delivery Despite many years of research, photoacoustic and thermoacoustic molecular imaging still has a lot of issues that need to be addressed promptly. The following future directions should be discussed: (1) There are limited categories of thermoacoustic contrast agents. Special superparamagnetism and bulk effect, the compounding of superparamagnetic nanoparticles, and their application in biomedicine will hopefully draw the attention of research fellows. Such methods show potential for the advance in multimodality technology of PAI, TAI and MRI; (2) The quantitative capability of photoacoustic and thermoacoustic molecular imaging is significant. It may help us differentiate benign from malignant lesions as well as obtain absolute tissue functional information. They are perhaps determinants of molecular typing. Besides, PAI and TAI can measure the amount of a drug at its site which will provide the theoretic foundation for ensuring the accuracy of injection doses for animals and patients; (3) The future research of contrast agents as a drug delivery system should emphasize its effectiveness and safety. The technical specifications of the system’s effectiveness and safety are not established yet. How to reduce toxicity and side effects as well as improve the drug targeting, solubility, stability, slow releasing action, and how to change tissue-targeted distribution and metabolism are key issues for this research; (4) Mono-modality imaging cannot obtain all the information required. Compared to low resolution ultrasound imaging, TAI can distinguish adsorbers which have the same acoustic impedance but different dielectric properties. PAI is also able to capture information about optical absorption with high resolution. Compared to PET and SPECT, these two imaging technologies have no risk of causing injury by radiation. Compared to MRI, PAI and TAI have quicker imaging speed. In comparison to OCT, they have longer imaging depths. Overall, PAI and TAI only demands imple equipment, have low cost, and are easy to operate, thus they have broad and applicable prospects. The combination of TAI and PAI is capable of revealing information such as water and ion concentration, blood volume, and oxygenation of hemoglobin. The preponderance complementarity of PAI, TAI, and other imaging modes will significantly improve medical high-tech, which will lead to more comprehensive sources of information about structural and functional physiology and pathology; (5) Unfortunately, the application of photoacoustic and thermoacoustic contrast agents in real time imaging and their ability to confirm lesions before treatment cannot currently meet the needs of modern medicine. Instead, targeted drug delivery systems, advanced physical therapy, image guided surgery, heat therapy , photothermal therapy, and magnet fluid hyperthermia are therefore the developing directionfor the future. Photoacoustic and thermoacoustic molecular imaging aim to integrate detection, monitoring, and reasonable treatment into one entity; (6) Contrast agent testings are too complicated, due to their specific animal testing experiments, longer experiment durations followed by clinical trials and high research and development costs. It has been concluded that the related research is unsystematic, has no unified standard, and is rarely used in the clinic due to various differences in species, individuals, and drug delivery systems. Therefore, the effectiveness and safety of photoacoustic and thermoacoustic molecular imaging play a key role in establishing better and more direct relations between basic research and clinical applications.Photoacoustic and thermoacoustic molecular imaging, working in tandem with powerful contrast agents, could provide groundbreaking opportunities for early diagnoses, precise lesion localization, molecular typing, drug delivery monitoring, image guided surgery, drug targeting therapy, and photothermic therapy of various diseases (such as cancer and cardio-cerebrovascular disorders). Photoacoustic and thermoacoustic molecular imaging, complemented by the development of such agents, will potentially bridge the gap between bench and bedside and further develop translational medicine as we know it.


The safety of bee venom as a therapeutic compound has been extensively studied, resulting in the identification of potential adverse events, which range from trivial skin reactions that usually resolve over several days to life-threating severe immunological responses such as anaphylaxis. In this systematic review, we provide a summary of the types and prevalence of adverse events associated with bee venom therapy.We searched the literature using 12 databases from their inception to June 2014, without language restrictions. We included all types of clinical studies in which bee venom was used as a key intervention and adverse events that may have been causally related to bee venom therapy were reported.A total of 145 studies, including 20 randomized controlled trials, 79 audits and cohort studies, 33 single-case studies, and 13 case series, were evaluated in this review. The median frequency of patients who experienced adverse events related to venom immunotherapy was 28.87%  in the audit studies. Compared with normal saline injection, bee venom acupuncture showed a 261% increased relative risk for the occurrence of adverse events  in the randomized controlled trials, which might be overestimated or underestimated owing to the poor reporting quality of the included studies.Adverse events related to bee venom therapy are frequent; therefore, practitioners of bee venom therapy should be cautious when applying it in daily clinical practice, and the practitioner’s education and qualifications regarding the use of bee venom therapy should be ensured. Bee venom is one of the most commonly encountered animal venoms and consists of various chemical agents that induce allergic reactions in the human body . Bee venAlthough the therapeutic utility of bee venom has been demonstrated, its safety profile is an important limiting consideration, because immune responses to BVT can range from trivial skin reactions that resolve over several days to life-threatening responses such as anaphylaxis  7]. In . In 7]. The most significant issue related to the AEs of BVT is that the occurrence of SAEs is unpredictable. It is therefore necessary to determine the prevalence and nature of AEs related to various types of BVT, so that bee venom can be used safely in clinical practice. The aim of this systematic review was to provide summary information regarding the types of AEs related to BVT and their prevalence in treated patients.All types of clinical studies, including randomized controlled trials (RCTs) and randomized crossover trials, as well as observational studies, including cohort studies, case-control studies, case series, and case studies, were included in this study.The subjects of the studies evaluated in this review included adults and pediatric patients, and the selection was not limited to studies of patients with specific diseases. Regardless of a patient’s condition and disease status, studies were included if bee venom was used as a key intervention, and AEs that may have been causally related to BVT were reported.In this review, we included studies of bee sting acupuncture (BSA), a subcutaneous or intramuscular injection of bee venom for the purpose of acupoint stimulation , and dried honeybee venom (apitoxin injections), as well as subcutaneous VIT for desensitization of venom immune reactions. BSA, BVA, SBV, and apitoxin injections usually involve the use of venom derived from bees (family Apidae), whereas VIT generally involves the use of venom from bees (family Apidae) and wasps (family Vespidae) concomitantly. Therefore, we included all types of venom therapy including both bee and wasp venoms. We also reviewed studies where bee venom was used alone or in combination with other treatments. However, studies describing bee stings resulting from random encounters , sting challenge tests, sublingual VIT, and irrelevant venom types were excluded from this study. We included RCTs comparing BVT with no treatment, normal saline injections, and conventional medications for relative risk assessment. Trials in which different types of BVT were compared with each other were excluded.The major aim of this review was to identify the frequency and types of AEs related to BVT. In case studies and case review series, the type of AE was classified into 1 of 3 categories: SR, skin problem (SP), and other . If an SR occurred as an AE, it was classified into 1 of 5 categories based on the Mueller classification  . The cauIn audits and cohort studies, AE types were divided into SR, large local reaction (LLR), local reaction (LR), and other . An LLR was defined as swelling exceeding 10 cm in diameter and lasting longer than 24 h, and an LR was defined as local pruritus, edema, or erythema . FinallyThe following 12 databases were searched: PubMed, EMBASE, the Cochrane Library, CINAHL, China National Knowledge Infrastructure (CNKI), Wanfang (China), Weipu (China), KoreaMED, the Korean Medical Database (KMBASE), the Korean Studies Information Service System (KISS), National Discovery for Science Leaders (NDSL) (Korea), and the Oriental Medicine Advanced Searching Integrated System (OASIS) (Korea). Bibliographic references in relevant publications  were manually searched to avoid missing eligible articles. The References sections of reviews on AEs of BVT were searched manually, and articles published through June 2014 were included. The search terms consisted of two parts: “BVT”  and “adverse events” . The search strategy was modified appropriately according to the databases. The detailed search strategies for PubMed, China National Knowledge Infrastructure (CNKI), Wanfang (China), Weipu (China), KoreaMED, the Korean Medical Database (KMBASE), the Korean Studies Information Service System (KISS), National Discovery for Science Leaders (NDSL) (Korea), and the Oriental Medicine Advanced Searching Integrated System (OASIS) (Korea) are presented in the Supporting Information.Two independent reviewers (JHP and BKY) screened the articles for inclusion by title and abstract. If disagreements regarding the selection of a study could not be resolved through discussion, the final decision was made by the arbiter (THK).One reviewer (JHP) read the full text of the articles selected for review and extracted the data using a standard data extraction form. Another reviewer (BKY) rechecked the data to ensure that it had been extracted appropriately. Any disagreement among the reviewers was resolved by discussion or by the arbiter (THK).To evaluate the quality of the detection and reporting of the AEs in the included RCTs, 7 items were assessed according to the CONSORT recommendations for harm data: (1) mention of AEs in the title or abstract, (2) mention of BVT-related AEs in the introduction, (3) predefined definition of AEs related to BVT, (4) collection or monitoring method for AEs, (5) mention of the method for analyzing and presenting AEs, (6) mention of any patients who dropped out of the study owing to AEs, and (7) mention of the specific denominator for the analysis of AEs  15]. Th. Th15]. http://ims.cochrane.org/revman).A meta-analysis of the RCTs was conducted if the incidence of AEs was clearly reported and the relative risk of AEs could be assessed because of similar study designs and intervention methods, including BVT types and control interventions, with minimal clinical heterogeneity. The relative risk of BVT and control interventions was assessed, and effects were calculated using Revman 5.2 software , reviews (57), surveys (3), studies without description of the assessment of AEs (43), and studies without relevant intervention or comparison groups (11). Finally, 145 studies, including 20 RCTs, 79 audits and cohort studies, 33 single-case studies, and 13 case series, were included in the review .Thirty-three single-case studies and 13 case series were identified as described in AEs were also reported in 79 mainly retrospective audit studies that aimed to assess the safety of BVT  60–138]–13860–13Eighteen RCTs and 2 randomized crossover trials were included in this review  139–158158. One-The meta-analysis of AE occurrence in the 4 RCTs assessing patients experiencing AEs showed that BVA increased the risk of AEs by 261% compared to the risk associated with normal saline control treatment . We also found that there have been SAEs associated with BVT that urgently required subcutaneous adrenaline or steroid and oxygen therapy, with death occurring in 1 case  [51] 5858. AsideIn 46 audits and cohort studies of VIT, the median incidence of AEs was 28.87%, and SRs occurred in 681/4844 (14.06%) participants. These results suggest a more frequent AE incidence in comparison with that in previous systematic reviews of VIT, which reported SR incidences of 11.5 to 11.8%  160]. I. I160]. Skin tests allow practitioners to distinguish whether BVT is an appropriate intervention for particular patients. In most RCTs and randomized crossover trials with BSA and BVA, participants were included if they showed negative responses in skin tests, whereas participants were included in VIT case studies and case series if they showed positive responses in skin tests. This difference in the participants included in each type of study does not seem to be directly related to the AEs associated with BVT; negative venom skin test results are not always a guarantee of VIT safety . HoweverVenom concentration and the frequency of venom administration can influence the severity and rate of incidence of AEs resulting from BSA and BVA. Unfortunately, we could not analyze the effect of venom concentration and administration frequency on the severity and rate of incidence of AEs because only limited numbers of RCTs were included in this review.With regard to the quality of reporting of AEs in RCTs, CONSORT items were generally not reported properly. Future RCTs with BVT must adopt the CONSORT AE reporting guidelines to ensure transparency and accuracy. When designing protocols, methods of AE assessment based on the CONSORT AE reporting guidelines should be suggested in detail.AEs related to BVA or VIT have been reported in various studies, including surveys  162] [1 [1162]  and reviThis review has some limitations. First, the heterogeneity of intervention in the reviewed articles was high; thus, the exact AE incidence and risk associated with the treatment methods could not be calculated. Second, although different venoms were used in different therapies , AEs from VIT were not classified in terms of the type of venom, treatment protocol , or phase (induction and maintenance).While it is evident that BVA clearly increases the risk of AEs in comparison with normal saline, our review revealed that BSA and BVA are often implemented without a skin test, and also showed that patients have experienced SAEs that can be fatal after receiving BSA from unqualified personnel. Therefore, in order to enhance the safety of BVT, a skin test should be conducted before BVT is administered, and the venom should be administered only by qualified individuals .Based on the results of this review, several suggestions can be made to support effective clinical practice and future clinical trials with BVT. In order to support responsible use of BVT, educational materials on the safety and efficacy of BVT should be made available for patients. Moreover, practitioners should be aware of the various AEs associated with BVT, establish clinical guidelines to minimize the development of AEs, and develop and implement strict criteria for monitoring AEs once they occur.AEs related to BVT are not uncommon. Therefore, BVT practitioners should pay careful attention to the incidence of AEs and patterns of AE occurrence in their patients. Additionally, education and qualification of BVT practitioners should be ensured based on appropriate training programs and clinical guidelines for monitoring of AEs related to BVA and BSA. Furthermore, when reporting AEs in RCTs evaluating BVT, researchers should describe AEs in detail according to the CONSORT recommendation for harm data to ensure transparency and accuracy.S1 File(DOCX)Click here for additional data file.S2 File(DOC)Click here for additional data file.


In the Russian Federation (Russia), an elevated burden of premature mortality attributable to non-communicable diseases (NCDs) has been observed since the country's economic transition. NCDs are largely related to preventable risk factors such as unhealthy diets.This health policy study's aim was to analyze past and current food production and nutritional trends in Russia and their policy implications for Russia's NCD burden.We examined food security and nutrition in Russia using an analytical framework of food availability, access to food, and consumption.Agricultural production declined during the period of economic transition, and nutritional habits changed from high-fat animal products to starches. However, per-capita energy consumption remained stable due to increased private expenditures on food and use of private land. Paradoxically, the prevalence of obesity still increased because of an excess consumption of unsaturated fat, sugar, and salt on one side, and insufficient intake of fruit and vegetables on the other.Policy and economic reforms in Russia were not accompanied by a food security crisis or macronutrient deprivation of the population. Yet, unhealthy diets in contemporary Russia contribute to the burden of NCDs and related avoidable mortality. Food and nutrition policies in Russia need to specifically address nutritional shortcomings and food-insecure vulnerable populations. Appropriate, evidence-informed food and nutrition policies might help address Russia's burden of NCDs on a population level. No meu prato que mistura de Natureza!As minhas irmãs as plantas,As companheiras das fontes, as santasA quem ninguém reza…Alberto Caeiro, “O Guardador de Rebanhos – Poema XVII”, 8 Mar 1914Availability of and access to a healthy variety of safe food are a prerequisite for healthy nutrition and health promotion. The three leading risk factors contributing to disease burden in the Russian Federation (Russia) are diet, alcohol use, and hypertension . A high perestroika) and opening (glasnost) of the socialistic planned economy towards free economic markets. These enormous political and economic changes are now known to have ended with the collapse of the Soviet Union in 1991. The collapse had profound effects on the economy and food policy of its successor, the Russian Federation. Currently, the country faces an unprecedented health crisis attributable primarily to NCDs that negatively affects the economic well-being of individuals and households and might become a barrier to economic growth  and searched the bibliographies of the retrieved articles written by experts in food and nutrition in the Russian country context.We selected studies according to the following criteria: 1) reporting of food availability, production, and/or consumption, 2) reporting of nutrition indicators , and 3) reporting of dietary or food habits. Drawing from identified peer-reviewed and grey literature, our framework uses primary concepts of food security analysis, that is, availability of food, access to food, and nutrition .Russia was the largest country of the Soviet Union and had vast potential resources to supply its population with ample quantities of fresh meats and dairy products. These were consumed at affordable prices due to the central planning system which coordinated and assured distribution to the population . Since tEarly Soviet policies pushed for the consumption of livestock products. The recommended daily intake for protein set by the former Soviet Union's Ministry of Health was almost twice that of Europe and North America, creating the erroneous belief that such high intakes of fat and protein are necessary for maintenance of health . The totdachas (weekend homes) out of economic necessity , the overall food consumption in Russia stayed constant. According to data from the Russian State Commission for Statistics (Goskomstat) household surveys, the average energy availability remained at about 2,900 kcal per-capita per day from 1990 to 2000, well above the Food and Agricultural Organizations of the United Nations (FAO) energy requirement guidelines of about 1,900 kcal per-capita per day . Other idachas) to produce food for their own consumption. Households also increased the proportion of their income spent on food, and individuals changed their dietary habits away from expensive  livestock towards vegetables and starchy foods.Several factors have contributed to Russian consumers’ stable food access and maintenance of caloric intake. While agricultural production was falling, incomes were decreasing, and food prices were rising . Both ruMuch of the literature on food security in Russia focuses on the debate of changes in agricultural policy. Changes in agricultural production and consumption, adjustment of consumer purchase behavior following the abolition of massive consumer subsidies, and their replacement by actual scarcity prices for agricultural products were all likely inevitable consequences of the economic reforms. FAO asserts that these trends also reflect the comparative advantage of Russia in the production of crop rather than livestock .Although on average food consumption remained above FAO energy recommendations , during During the economic crisis from 1992 to 1998, the proportion of overweight among children aged 6–18 years decreased (from 15.6 to 9.0%), while underweight increased (from 6.9 to 8.1) , Asian 16%), or African countries (33%) , as well as the unemployed, lost their purchasing power to maintain a healthy diet.The increase in income inequality resulting from the economic transition added to the vulnerability of affected households. The country's later macroeconomic growth over the past 10 years contributed to a reduction of poverty and narrowed this gap by reducing poverty rates from 2.1% in 2005 to 1.0% in 2013  in the Ministry of Industry and Power, Rosselkhoznadzor  in the Ministry of Agriculture, and Rospotrebnadzor  in the Ministry of Public Health and Social Development  and more than 700 state laws and standards and governmental orders regulating food production in Russia. Russian standards partly even exceed EU regulations (e.g. for safe tetracycline concentrations or for food additives in baby food) or food safety standards set by FAO/WHO in Codex Alimentarius  is obese. The prevalence of overweight and obesity in Russia has been increasing over the past three decades . In adulCompared to their Central and Eastern European counterparts, Russians have the highest mean energy intake, with total fat as the main source, mostly provided by monounsaturated fat . AssessiThese unhealthy diets create risk factors for various cardiovascular diseases, cancers, chronic diseases such as diabetes and osteoporosis, and many more. Attributable to the Russian diet that has remained high in unsaturated fat and salt, and low in fruit and vegetables particularly outside harvest season, disorders of the circulatory system increased by 18%, endocrine disorders by 18%, and neoplasm by 16% during the economic transition .Although trends indicate that the overall consumption of high-fat livestock product and sugar has decreased , people The current preeminent nutritional problem for children of all ages in Russia is overweight. Latest available data from the Health Behaviour in School-aged Children survey suggest that overweight in Russia is higher during early adolescence, as up to 32% of boys and 18% of girls among 11-year-olds were overweight , rates wThe few available data on breastfeeding indicate that rates have remained low . AccordiStunting, that is low height for age, is usually the result of chronic malnutrition early in life, a concept that has recently focused on the first 1,000 days of life from conception to 2 years of age. Stunting in Russian children under 5 years of age has been estimated to be as high as 13% . MicronuRussia is currently experiencing an exponentially increasing double epidemic of injection drug use and HIV infection. This has created a rapidly growing but mostly overlooked vulnerable population at risk for malnutrition, people who inject drugs (PWID) and people living with HIV (PLWH). Malnutrition and food insecurity are exacerbated in these patient groups but are currently not routinely addressed in the care of PWID or PLWH in Russia.Among HIV-infected PWID, food insecurity increases the risks of HIV transmission to their non-infected sex partners. The increased risk is mediated by nutritional deficiencies, which further compromise immune status and increase transmission risk per unsafe sex act. In addition, poverty-related food insecurity triggers transactional sex and needle-sharing practices. Food-insecure, HIV-infected PWID also have less access to health services including ART. Even among those on ART, pharmacokinetic efficiency of the drugs remains low due to reduced energy intake.Russia's healthcare system is highly fragmented and does not address nutritional problems in the vulnerable population of HIV-infected PWID. While there are reliable estimates on the combined epidemic of drugs and HIV in the Russian Federation, there are currently no published data on nutritional status and food insecurity in these key populations. Studies from other concentrated HIV epidemics indicate high levels of food insecurity and poor nutritional status among PWID regardless of HIV status . In the In Russia, injection drug use  has been driving the HIV epidemic  and has Since the advent of the HIV epidemic, research in various settings has shown that HIV patients suffer from complex nutritional problems, notably wasting and micronutrient deficiencies . Many PWMalnutrition in HIV-infected PWID has various causes, including malabsorption related to both HIV infection and ART, as well as decreased dietary intake due to gastrointestinal pathologies, irregular lifestyle and limited access to appropriate food (both often related to drug use), or mental illness. An HIV-induced hypermetabolic state may also contribute to malnutrition in this population .Addressing nutritional issues in a specifically vulnerable population, that is PWID in the context of a concentrated HIV epidemic, with particular attention to micronutrient needs, has been a neglected aspect of a politically charged public health problem in Russia. Food and nutritional support for AIDS prevention among HIV-infected PWID should include not only brief screening and comprehensive assessments of nutritional status, counseling and education, and various food support interventions, but also advocacy and appropriate nutrition and HIV policies .Russia's burden of overweight contributes to the existing health crisis in the country. While gross national income has recovered over the past years, life expectancy and population size continue to decline. Appropriate national policies need to address the problem of malnutrition, which in Russia includes not only overnutrition but also micronutrient deficiencies and to a lesser extent undernutrition. Policies should also be tailored to the most vulnerable, that is women and children, populations in lower socioeconomic strata, and focus on high-risk groups such as HIV patients and PWID.To face the nutritional burden, Russia's national food and nutrition policy needs to go beyond agricultural policies to have a potential public health effect. Changing food prices alone is unlikely to substantially reduce BMI and obesity in Russia, as elasticities of BMI with respect to food prices are low, mostly smaller than 0.01 . The burRussian public health experts attribute the causes of malnutrition in Russia to the limited public awareness of healthy eating habits and to insufficient training of providers in delivering adequate nutritional counseling. They have argued that healthier dietary habits have to start early in life and need to be rooted in the communities, for example through sufficiently funded nutrition groups. Baby-friendly hospitals are a potential implementation site for programs in Russia to improve mother and child nutrition, focusing on improving breastfeeding practices and healthy maternal nutrition. Although established since 1996 in Russia, only a small number of deliveries (16%) occur in baby-friendly hospitals . Mother Policies need to specifically address Russia's food-insecure minorities. While there has been some international attention for people of lower socioeconomic status and populations living in the economically disadvantaged peripheral regions of the vast Russian Federation, there has been no focus so far on nutritional high-risk groups and key populations such as PLWH and PWID. One of the reasons is the immense stigma associated with these conditions. To overcome policy resistance against evidence-based management of these potential target groups, political, social, and religious leaders will have to overcome their own prejudices and actively address the stigma of HIV and drugs. It is a mandatory prerequisite for national food policies to bring progress for Russia's nutritionally vulnerable and food-insecure minorities.Policy resistance against limiting a flourishing food industry and lack of funding for public health nutrition programs are expected barriers towards halting and reversing current nutritional trends. Similar to experiences of Western countries, Russia's school-aged children face an environment rich in advertisements and offerings of calorically dense, processed food and soft drinks, like candy, snacks, and sugared beverages . HoweverThe Russian Government's key policy ‘Concept 2020’ and its framework for the national health strategy ‘Healthcare Development Concept to 2020’  aims to Despite economic instabilities that accompanied Russia's economic transition, the country fares better in food adequacy than many other countries in the area. Russia's main food-related challenges are unhealthy nutritional habits, closely related to unhealthy alcohol use.Changing lifestyles and nutritional habits is certainly a complex process and demands a comprehensive approach championed by political and societal leadership, translated to the population through evidence-based programs. A public health approach, that is a population-based shift towards healthier nutrition could not only relieve Russia's premature mortality burden, but also its immense economic effects.


Background: The barriers to HIV testing and counselling that migrants encounter can jeopardize proactive HIV testing that relies on the fact that HIV testing must be linked to care. We analyse available evidence on HIV testing and counselling strategies targeting migrants and ethnic minorities in high-income countries. Methods: Systematic literature review of the five main databases of articles in English from Europe, North America and Australia between 2005 and 2009. Results: Of 1034 abstracts, 37 articles were selected. Migrants, mainly from HIV-endemic countries, are at risk of HIV infection and its consequences. The HIV prevalence among migrants is higher than the general population’s, and migrants have higher frequency of delayed HIV diagnosis. For migrants from countries with low HIV prevalence and for ethnic minorities, socio-economic vulnerability puts them at risk of acquiring HIV. Migrants have specific legal and administrative impediments to accessing HIV testing—in some countries, undocumented migrants are not entitled to health care—as well as cultural and linguistic barriers, racism and xenophobia. Migrants and ethnic minorities fear stigma from their communities, yet community acceptance is key for well-being. Conclusions: Migrants and ethnic minorities should be offered HIV testing, but the barriers highlighted in this review may deter programs from achieving the final goal, which is linking migrants and ethnic minorities to HIV clinical care under the public health perspective. To be eligible, articles had to include at least one keyword from: (i) ethnic groups, minority groups, transients and immigrants, refugees; (ii) mass screening, diagnosis, AIDS Serodiagnosis, public policy, prevention and control, Centers for Disease Control and Prevention (USA), counselling; and (iii) Acquired immunodeficiency syndrome, HIV, HIV Infections.After piloting in 14 articles, the final data collection form included information on year and country of the study, ‘migrants’ and ‘ethnic minorities’ definition, setting, study design and sample size. Information on gender, criminalization of HIV transmission and legal consequences of HIV disclosure in migrants with uncertain status was also collected.As described in n = 22), they did not deal with migrants or ethnic minorities (n = 13), countries did not meet criteria (n = 3) or they were of poor quality (n = 1). The review of these 64 articles identified seven new manuscripts, from the manuscripts’ references, of which four met inclusion criteria. Final analyses were based on 37 articles.Teams of two people read the 64 articles and applied eligibility criteria; 31 articles were rejected because they did not deal with HIV testing (n = 35) was conducted in one country, most (n = 20) with local scope. Studies were conducted in health (n = 15) and community settings (n = 11) (supplementary table). Overall, 25 studies (68%) used quantitative methodology, two combined quantitative and qualitative methodology, six used qualitative methodology and four were literature reviews. Operational definitions for ‘migrant’, ‘race’ or ‘ethnicity’  were present in all articles; more than one definition was often present; 14 defined migrants based on country of origin, 13 on country of birth and 3 on nationality. With regards to race and ethnicity, eight studies (mostly from USA) defined subjects on self-reported ethnicity and nine on documented ethnicity (n = 7), ethnic origin (n = 1) and race (n = 1).Most studies were conducted in Anglo-Saxon countries—12 in USA, 4 in Canada, 13 in the UK—and 8 from other European countries. None of the articles was from Australia. The majority  prevalence and risk factors for HIV infection; (ii) barriers to HIV testing; (iii) HIV testing uptake; (iv) late HIV diagnosis; and (v) interventions to encourage HIV testing.Although our aim was not to systematically review HIV prevalence and risk factors in migrants and ethnic minorities, this topic came up frequently. Although many articles include general references to this issue, studies that report data about differential prevalence of HIV have been included in ,,,,,,,,Epidemiological patterns in countries of origin, together with clinical presentations in countries of destination, led some authors to conclude most HIV infections in migrants are imported. This approach is largely applied to migrants from SSA in Europe  are considered especially vulnerable; female migrants suffer disproportionate burden of HIV infection derived from difficulties negotiating condom useBarriers to HIV testing exist at the structural, health-care provider, health-care user and community levels.,,,,,,,Structural barriers to HIV testing relate to poor living conditions, legal and administrative status and discrimination in countries of destination. High levels of unemployment and poverty in migrants and ethnic minorities, low social status and inequalities are mentioned as barriers to HIV testing and care.,,,,,,,,,,,,Within health-care structures, communication, language problems and lack of cultural sensitivity and underinvestment in culturally competent services lead to misconceptions about migrants and minority groups by health-care providers.,,,,,,,At the community level, cultural and gender norms may dissuade heterosexual men and women and MSM from seeking HIV testing. Loss of status and community support and social isolation after confidentiality gaps are among the main reasons given for not testing.,,,,,,,Several studies describe an HIV testing uptake in migrants and ethnic minorities to range from 21% to 73% in the USA and from 23% to 64% in EuropeThe context in which testing is offered and who offers the test seem to be important determinants of test acceptance. For example, in a US study, 70% of Hispanic migrant farm workers reported they would accept testing recommended by a health-care provider, with women more likely than men to accept testing.,,,,,,High prevalence of delayed diagnosis of HIV infection in migrants and ethnic minorities was reported, largely among sub-Saharan Africans in the UK,López-Quintero et al.The literature identified two main approaches to HIV testing: general population approaches in health-care settings and targeted approaches directed to at-risk populations, including migrant and/or ethnic minorities. In both cases, specific interventions to encourage the participation of migrants and ethnic minorities are discussed. Among the targeted approaches, voluntary or compulsory HIV testing strategies are analysed.Antenatal screening is an example of a population-wide approach; various studies support routine antenatal testing for all pregnant women as an effective strategy for achieving good coverage of HIV testing in migrant and ethnic minorities.,,,Health-care provider endorsement was identified as a significant predictor of HIV testing. Some authors recommend mixed approaches; introducing HIV screening in routine medical practice in addition to targeted strategies in place, particularly in areas with high HIV prevalence and a concentration of migrant population.,,,Many authors indicated that culturally sensitive HIV testing and counselling interventions are needed to improve institutional access to health services to promote HIV testing among migrants and ethnic minorities.,Innovative targeted approaches to reach people who might not otherwise use testing services include the provision of HIV rapid testing in non-traditional health-care settings outside normal working hours.,Another approach specifically targeting migrants is screening on arrival in the country. US policy requires HIV testing for asylum seekers,,,,,,,,,,,,,,,,,,This systematic review has found that migrants, largely those from HIV-endemic countries, are at high risk of HIV infection and its consequences.,,,Testing migrants for HIV may take place either in the context of general population strategies in health-care settings—such as antenatal testing—or targeted approaches among specific populations. HIV testing uptake in antenatal settings in migrants is high and similar to that of non-migrant women. Women from HIV-endemic countries prefer general population strategies that are integrated within health services.,,,,A key aspect—often undermined—is the heterogeneity of migrant populations, which requires tailored strategies for some groups. It is essential to discuss and implement interventions in partnerships with the communities. Test performance in non-traditional settingsThere are a number of study limitations that merit discussion. Although our aim was not to review studies on HIV prevalence and risk factors in migrants and ethnic minorities, these subjects came up in a large number of studies. However, we realize that the search strategy used provides only a partial view on these topics. We are also aware this search covers only articles in English; research in other languages, the grey literature and conference abstracts are not included. The methodology used in this systematic review does not permit a comprehensive assessment of the extent to which mandatory HIV testing is applied to migrants.,There is increasing evidence in recent years of the benefits of HIV testing at the individual and community levels.Supplementary Data are available at EURPUB online.European Centre for Disease Prevention and Control, the Spanish Network of HIV/AIDS Research [RIS—RD06/0006] and the CIBERESP .This work has been financed by the Conflict of interest: None declared.Migrants, mainly from HIV-endemic countries, are at high risk of HIV infection and its consequences. Their HIV prevalence is higher than in the general population, they have higher frequency of delayed HIV diagnosis and are more vulnerable to the negative effects of disclosure of HIV status. For migrants from countries with low HIV prevalence, socio-economic vulnerability puts them at risk of acquiring HIV in destination countries.Migrants have specific legal and administrative impediments in accessing health services and HIV testing—in some countries, undocumented migrants are not entitled to health care—as well as cultural and linguistic barriers, racism and xenophobia. Migrants fear stigma from their communities, yet community acceptance is key for well-being.Although there is increasing evidence of the benefits of HIV testing at both the individual and community levels, the barriers highlighted in this systematic review may prevent programs from achieving the final goal, which is linking migrants and ethnic minorities to HIV clinical care under the public health perspective.


There is growing recognition that operational research (OR) should be embedded into national disease control programmes. However, much of the current OR capacity building schemes are still predominantly driven by international agencies with limited integration into national disease control programmes. We demonstrated that it is possible to achieve a more sustainable capacity building effort across the country by establishing an OR group within the national tuberculosis (TB) control programme in Indonesia. Key challenges identified include long-term financial support, limited number of scientific publications, and difficulties in documenting impact on programmatic performance. External evaluation has expressed concerns in regard to utilisation of OR in policy making. Efforts to address this concern have been introduced recently and led to indications of increased utilisation of research evidence in policy making by the national TB control programme. Embedding OR in national disease control programmes is key in establishing an evidence-based disease control programme. The importance of operational research (OR) for improving programmes and services has become increasingly recognised by the global health community . OR is cThere have actually been many health research capacity building programmes developed for LMICs. The American Thoracic Society Methods in Epidemiologic, Clinical and Operations Research (ATS MECOR) programme began in Latin America as the International Respiratory Epidemiology course in 1994 and, in its 18th year, has developed into a five-level programme with a range of competencies . ProgramWe applaud the OR capacity building initiatives illustrated above. However, we note that these reputable initiatives are still predominantly driven by international agencies, with limited embedding into national disease control programmes. OR is best prioritised, designed, implemented, and replicated from within national disease control programmes , 8. We aIndonesia has a strong foundation in research, with a record of conducting OR before implementing a new strategy, such as short-course chemotherapy, DOTS including MDR-TB and TB/HIV management and hospital DOTS linkage –11. PrepTORG members are experienced researchers from reputable public and private universities in Indonesia as well as representatives from the NTP and the National Institute of Health Research and Development. The official tasks of TORG are: 1) to provide technical assistance for conducting OR at the provincial/district level; 2) to facilitate capacity building for conducting and utilising OR at provincial level through intensive courses; 3) to provide review on relevance of independent OR proposals submitted to the national TB programme; and 4) to provide recommendations for evidence-based improvement of the national TB programme based on OR. A secretariat for TORG is provided within NTP.Subsequently, since 2005, there has been an extensive scaling up of OR activities facilitated by TORG. These activities included: a district TB financing study providing evidence on the need for increased budget commitment at local level; a pilot study of TB-HIV surveillance which provided basis for a national TB-HIV policy; a study on TB case management in hospitals and the economic evaluation on public–private mix schemes strengthening evidence-based planning of network enforcement including all healthcare providers; and evaluation of intensified introduction of Xpert MTB/Rif in Indonesia. The increase in research activities is partly the result of high financial commitment achieved through wide donor support, notably DFID, USAID, and GFATM. Key to the success in the increase in research activities has been the participation of a broad range of national and international partners in conducting research and providing technical assistance. TORG has also made efforts to better align OR projects with NTP priorities by formulating the national OR agenda and organising call for proposals on behalf of NTP.Designing and Conducting Health System Research Project  and publication writing (limited capacity for academic English writing).Up to 2013, a total of 56 OR projects have been conducted, of which 46 were successfully completed (33 by participants of the intensive workshops) and 35 have been disseminated to key stake holders . The OR Box 1Putra IW, Utami NW, Suarjana IK, Duana IM, Astiti CI, Putra I, et al. Factors associated to referral of tuberculosis suspects by private practitioners to community health centres in Bali Province, Indonesia. BMC Health Serv Res 2013; 13: 445.Rintiswati N, Mahendradhata Y, Suharna S, Susilawati S, Purwanta P, Subronto Y, et al. Journeys to tuberculosis treatment: a qualitative study of patients, families and communities in Jogjakarta, Indonesia. BMC Public Health 2009; 9: 158.Sakundarno M, Nurjazuli N, Jati SP, Sariningdyah R, Purwadi S, Alisjahbana B, et al. Insufficient quality of sputum submitted for tuberculosis diagnosis and associated factors, in Klaten district, Indonesia. BMC Pulm Med 2009; 9: 16.Wahyuni CU, Budiono, Rahariyani LD, Sulistyowati M, Rachmawati T, Djuwari, et al. Obstacles for optimal tuberculosis case detection in primary health centers (PHC) in Sidoarjo district, East Java, Indonesia. BMC Health Serv Res 2007; 7: 135.Within the period of 2003–2013, TORG successfully worked through successions of four Ministers of Health and four NTP managers. All four NTP managers were in general appreciative of the need for research evidence to support programme improvement. The current NTP manager in particular is highly engaged with TORG, for instance, in conduct of recent studies of strategic importance such as a survey of TB case management practices among private practitioners, implementation of Xpert MTB/RIF in five sites in Indonesia, a national TB prevalence survey, and estimates of TB prevalence. These studies have informed current policies of NTP. The current NTP management also promotes dissemination of OR activities through supporting presentations at international conferences, providing funding for publication in open access journals, and supporting submission to competitive calls for proposals (e.g. TB REACH).Though TORG collaborates directly with the NTP, it should be noted that Indonesia's health system is highly decentralised, making collaboration with public health authorities at provincial and district level necessary. Accordingly, TORG's approach in capacity building has been based on training and mentoring of provincial district teams. The impact of TORG within policy networks across districts, beyond written commitments on changing policies and/or practices by policy makers signed during dissemination meetings, however, remains to be documented.Recent results from Joint External Monitoring Mission conducted in 2011 and 2013 (unpublished) highlighted current challenges for TORG, noting: 1) limited impact on the performance of the TB control programme; 2) mechanism to propose, initiate, and conduct OR research has not been integrated and implemented within day-to-day programmatic activities in the provinces and districts despite the training; 3) OR findings have not been used optimally for policy development; 4) conducting OR is a part-time job, because investigators typically have other programmatic or academic duties; and 5) important programmatic issues such as reasons for low notification of previous treatment history and decreasing treatment success rate in large facilities have not yet been investigated.TORG's activities have received financial support from USAID through various channels. USAID funding between 2004 and 2005 has been channelled through TBCTA . This was continued between 2005 and 2010 through TB CAP (TB Control Assistance Program). Since 2011, funding has been channelled through TB CARE I. Moreover, TORG has received some financial support for courses and projects through Global Fund Round 8 which has been available since 2009. TORG has also received technical assistance from KNCV Tuberculosis Foundation (including mentoring) since its establishment in 2004 and has continued until the time of writing.We have demonstrated that it is possible to actually embed OR into a national disease control programme, leading to long-term capacity building effort across the country. The main funding sources until now however are still from international agencies. It will be challenging to find local funding in the near future to sustain TORG and its activities in the long run. Long-term financial challenges are apparently also faced by other OR capacity building initiatives , 14, 15.Notably, the Ministry of Health has formulated an exit strategy from grants of the GFATM . SpecifiThe intensive OR course was originally designed in 2004 based on a two-volume main reference , 13. TheScientific publications have been touted as one of the key performance indicators of OR . Thus, tThe success in terms of scientific publications, however, arguably is also influenced by the heterogeneity of participants’ aptitude and abilities . This highlights the need for more intensive supervision and mentoring, particularly for groups which show problems in aptitude and abilities during the workshop. Notably, access to peer-reviewed international publication had not been identified as a major obstacle. This may reflect the increasing availability of open access scientific publications in the past decade as well as the support of TORG mentors, which include, if necessary, assisting in obtaining essential literatures.The performance of Indonesia's NTP has been exemplary in recent years as highlighted in the Joint External Monitoring Mission 2011 Report (unpublished) and the Joint External Monitoring Mission 2013 Report (unpublished), but it is difficult to actually attribute the contribution of OR to programmatic performance as there are so many other contributing factors  and there are also challenges of measurement . The JoiAssertions of limited impact to policy were apparently based on limited existing information because of lack of previous efforts to actually document policy uptake. Preliminary findings from an ongoing study led by Probandari et al.  suggest that the recommendations of at least half of the OR groups supported by TORG have been taken up in TB control policies to various extents. This has been attributed to the intensity of communications between the researchers, programme managers, and policy makers facilitated through the capacity building process. However, the high turnover of programme managers and policy makers in the provincial/district level has seemingly been a major bottleneck to long-term relationships and policy influence. Notwithstanding, TORG has recently introduced efforts in line with current concepts and good practices to improve utilisation of research results in policy making –22. TORGThe influence of OR on (evidence-based) policy building might vary across the country, because Indonesia has a highly decentralised health system with political responsibility down to district level . There iThere are other aspects of research impacts which have been proposed to be documented . HoweverMost importantly, TORG and similar initiatives to embed OR into disease control programme should move forward while taking stock of the key reflections from the years of experience, including: ensuring long-term perspective and commitment of key stakeholders; mobilising external technical and financial assistance to address critical gaps in local resources and capacities; instilling continuous learning for improvement and adaptation; identifying strategies for sustainability; demonstrating tangible results and practical impacts; and integrating OR indicators into the set of key performance indicators of the national disease control programme.