We used data from the Michigan Behavioral Risk Factor Surveillance System (MIBRFSS) to estimate the prevalence of adverse health outcomes by industry and occupation and to examine the association of adverse health outcomes with industry and occupation while controlling for demographics and personal lifestyle behaviors.We calculated the prevalence of adverse health outcomes by industry by using data from the 2013–2015 MIBRFSS. Adjusted prevalence of adverse health outcomes was calculated by industry and occupation by using logistic regression for survey design, adjusting for demographics and health behaviors, and was compared with the overall prevalence in all industries and occupations.Three industries had a significantly higher prevalence of current asthma, diabetes, and depression compared with prevalence among workers employed in all industries. After controlling for confounding factors, only Health Care and Social Assistance had significantly higher prevalence of a health outcome, depression (20.1%). Three occupations had significantly higher prevalence of chronic obstructive pulmonary disease, current asthma, depression, high blood pressure, and diabetes compared with workers employed in all occupations. After adjusting for all confounding factors, only one occupation, protective service, had a significantly higher prevalence of high blood pressure (37.3%) and diabetes (12.8%).Adverse health outcomes varied significantly by industry and occupation in Michigan. Employers, policy makers, and health promotion practitioners can use results based on BRFSS to target and prioritize worksite wellness programs. MIBRFSS data also suggested the need for further research to identify why some industries had higher risks for diabetes, hypertension, and depression after controlling for covariates. Healthy People 2020  is an annual telephone survey of adults aged 18 or older that is conducted independently by the states, the District of Columbia, and US territories and is coordinated through cooperative agreements with the Centers for Disease Control and Prevention (CDC). The survey comprises 3 parts: core survey questions, optional modules, and state-added questions. These state-based surveys provide state-specific, population-based estimates of the prevalence of various behaviors, medical conditions, and preventive health care practices by state  in cooperation with the states: 1) Industry – “What kind of business or industry do you work in, for example, hospital, elementary school, clothing manufacturing, restaurant?”; 2) Occupation – “What kind of work do you do, for example, registered nurse, janitor, cashier, auto mechanic?” All respondents who were employed for wages, self-employed, or out of work for less than one year at the time of their interview were defined as employed and were asked the 2 occupation and industry questions. Participants’ responses were coded to 2002 US Census Bureau industry and occupation numeric codes using the NIOSH Industry and Occupation Computerized Coding System and human coders. Census industry codes were grouped into the 20 Standard Industrial Classification (SIC) 2002 codes and 22 Standard Occupational Classification (SOC) 2000 codes for major groups. The industrial and the occupational category for military personnel were excluded from analyses because BRFSS data are not representative of those personnel.2 /weight in kilograms), smoking status, education level, income, exercise, binge drinking, and health insurance status. For each health outcome, we also obtained predicted prevalence for workers in all industry and occupation groups and compared this with prevalence in each industry and occupation.Data were weighted on the basis of an iterative proportional fitting methodology  to adjust for the distribution of the Michigan adult population by telephone source (landline or cellular phone), race/ethnicity, education level, marital status, age by sex, sex by race/ethnicity, age by race/ethnicity, and renter/homeowner status. To determine the prevalence of health outcomes by industry or occupation, we obtained weighted prevalence and 95% confidence intervals (CIs) based on the BRFSS sample survey design. Some industries’ results were suppressed following the BRFSS data guidelines: an unweighted denominator of fewer than 50 respondents or a relative standard error of greater than 30%. Results from 2 of the 20 industries, Management and Mining, were suppressed. For occupation, results were presented from 13 grouped occupations. Logistic regressions based on complex survey design were employed to predict the prevalence of different adverse health outcomes in different industries and occupations –9. All pWe performed analyses by using SAS –callable SUDAAN  and STATA (STATA Corp) software, and analyses were weighted to adjust for MIBRFSS survey sampling design. We considered the adjusted prevalence estimates to differ statistically if their 95% CIs did not overlap. This is approximately equivalent to setting the type I error for the null hypothesis at α = 0.006 level .The 2 outcomes addressed were 1) were there significant differences in the prevalence of adverse health outcomes in different industry and occupation groups compared with all employed workers and 2) were there significant differences in the prevalence of adverse health outcomes in different industry or occupation groups after controlling for confounding factors. MIBFRSS is de-identified and therefore exempt from institutional review board approval.Ninety-four percent of respondents completed the occupation questions, and 97% completed the industry questions. Manufacturing (18.8%) and Health Care and Social Assistance (15.7%) were the 2 most common industries in which respondents were employed (worked in the previous year). We assessed the distribution of demographic characteristics among all employed adults by industry . BecauseArts, Entertainment, and Recreation had a significantly younger population (21.4% were aged 18 to 24). In Public Administration, most of the employed population were aged 35 to 64 (over 70%), which was significantly higher than the overall proportion of the employed population in this age range .For racial/ethnic distribution, we found no notable differences in the Hispanic population by industry. A significantly low proportion of African Americans worked in Construction and in Wholesale and Retail Trade, and no African Americans reported working in Agriculture, Forestry, Fishing, and Hunting .We examined the prevalence of binge drinking, current cigarette smoking, and obesity by industry . The aveWorkers in Construction had the highest prevalence (37.2%) of binge drinking, which was significantly higher than the average prevalence of binge drinking among all employed adults (24.2%). Compared with the average binge-drinking prevalence among all workers, 3 industries — Educational Services, Health Care and Social Assistance and Other Services had a significantly lower prevalence of binge drinking; Health Care and Social Assistance had the lowest prevalence (17.7%) . Public We assessed by industry the prevalence of ever having asthma, cancer, chronic obstructive pulmonary disease (COPD), depression, diabetes, high blood pressure, and current asthma. Seven industries had a health outcome prevalence that was significantly greater for ever having asthma, cancer, COPD, depression, diabetes, and high blood pressure and for having current asthma than all industries combined, and 12 had a prevalence that was significantly lower . After cConstruction and Manufacturing had a significantly lower prevalence of current asthma compared with all workers but only in Manufacturing was the prevalence significantly lower after controlling for covariates. The significantly elevated prevalence in Accommodation and Food Services and in Health Care and Social Assistance did not persist after controlling for covariates  and 3. AWorkers in Agriculture, Forestry, Fishing, and Hunting had the lowest prevalence of ever having depression (6.5%). Workers in 3 other industries also had significantly lower prevalence of depression compared with workers in all industries while workers in Accommodation and Food Services had a significantly higher prevalence . AgriculFor cancer prevalence, the industry with the lowest prevalence of ever having any cancer was Accommodation and Food Services (3.0) . Health Prevalence of ever having diabetes and of ever having high blood pressure prevalence were lower in 4 industries than in all industries combined and higher in one . After cWe found that 8 occupations had a significantly higher prevalence of ever having COPD, depression, high blood pressure, diabetes, or current asthma compared with workers in all occupations , but onlThe prevalence of ever having high blood pressure was lower in the Accommodation and Food Services and in the Arts, Entertainment, and Recreation industries, and in the food preparation and serving-related occupations . These lThe prevalence of diabetes was significantly higher in the Arts, Entertainment, and Recreation industry and significantly lower in the Accommodation and Food Services industry and the Agriculture, Forestry, Fishing, and Hunting industry . After cOther states have examined differences in health outcomes by industry and occupation, but ours is the first analysis performed in Michigan. We waited to conduct analyses until we could combine 3 years of data to maximize the number of industry and occupation groups with sufficient sample size. However, even with 3 years’ worth of data, we did not have a sufficient sample size to separately present the results in 2 two-digit industry and 8 two-digit occupation groups. Besides being useful for Michigan prevention strategies, the analyses we conducted also add to previous literature that examined industry and occupation and BRFSS data by assessing prevalence by industry and occupation while controlling for important demographic factors, such as age, sex, and race, which are related to behaviors and health outcomes. Controlling for these demographic factors and behaviors, such as cigarette smoking, when examining health outcomes provides important information on interpreting whether differences in prevalence between industries and occupation are due to the health behaviors and demographics of the workforce in that industry or occupation or are possibly due to exposures or work practices associated with an industry or occupation.Workers in Accommodation and Food Services, and in Health Care and Social Assistance had a significantly higher prevalence of current asthma, but not after controlling for covariates. Manufacturing had a significantly lower percentage that persisted after controlling for covariates. Construction and Extraction occupations and Production occupations had significantly lower prevalence of current asthma. The lower prevalence in Production occupations persisted whereas the prevalence in Health Care Support was no longer greater after controlling for covariates. Dodd and Mazurek  used 201Analyses of the BRFSS data are useful to generate hypotheses for further research to explore differences between industries and occupations, to help focus primary prevention or secondary prevention action on certain worker groups, and to focus the priorities of industry worksite wellness programs. Better understanding of why certain industries and occupations have an increased prevalence of certain diseases despite controlling for known risk factors, such as cigarette smoking, may enable the identification of exposures or other modifiable risk factors. Simply comparing the prevalence without controlling for known risk factors can produce misleading interpretations. For example, depression and cancer are known to correlate highly with sex and age –11. AfteNone of the differences between industries or occupations for ever having cancer persisted after adjusting for covariates and therefore were not useful in generating hypotheses to identify occupational carcinogens. The prevalence of cardiovascular disease was not significantly different in any industry or occupation either before or after adjustment despite differences in risk factors such as smoking, obesity, diabetes, and high blood pressure.The analysis of health outcomes in conjunction with health behaviors is useful in considering alternative reasons for different findings by industry. For example, substantial differences in smoking prevalence were observed across different industries. COPD, which is highly associated with cigarette smoking, also differed among industries but not in the same way that cigarette smoking did . Three possible explanations for why cigarette and COPD prevalence differ within the same industry are 1) workers in industries with a high cigarette but low COPD prevalence  self-select out of the industry because of the strenuous work load, 2) industries with a low prevalence of smoking but a high prevalence of COPD  may have exposures that contribute to COPD, or 3) people with COPD move into this industry  once they develop COPD.The inclusion of the industry and occupation questions in BRFSS provides information that allows both behaviors and health outcomes to be evaluated in relationship to work. We chose to present the results of the industry question in the main text because generally, it both provides a better measure of exposure and it identifies targets for interventions. We present data by occupation in the appendixes. Certain occupations, such as teachers, firefighters, and police, are specific enough to provide the same information as industry, but most occupations, such as cleaner, laborer, manager, and mechanic, are present in many different industries and do not facilitate public health interventions.Our study had limitations. Despite widespread use to measure the prevalence of different diseases and behaviors at the state level, BRFSS data had limitations. First, health behaviors and outcomes were self-reported responses, and there was no review of medical records to check the validity of the responses. Second, results may not have been representative for the whole population, given a 50% response rate. Third, the data were cross-sectional, so the results were not evidence for causality but rather should be used to generate hypotheses.We examined the adverse health outcomes and health behaviors among different industry sectors for MIBRFSS 2013–2015. Our results showed that 3 industries , which employ 24% of the Michigan workforce, had 7 significantly higher prevalence rates for adverse health outcomes: ever any cancer, depression, diabetes, and current asthma. Prevention efforts targeting these 3 industries have the greatest potential to reduce the overall burden of these common conditions in Michigan. Similar analyses in other states would allow prevention strategies to be uniquely targeted on a state-by-state basis.


The inhalation route is frequently used to administer drugs for the management of respiratory diseases such as asthma or chronic obstructive pulmonary disease. Compared with other routes of administration, inhalation offers a number of advantages in the treatment of these diseases. For example, via inhalation, a drug is directly delivered to the target organ, conferring high pulmonary drug concentrations and low systemic drug concentrations. Therefore, drug inhalation is typically associated with high pulmonary efficacy and minimal systemic side effects. The lung, as a target, represents an organ with a complex structure and multiple pulmonary-specific pharmacokinetic processes, including (1) drug particle/droplet deposition; (2) pulmonary drug dissolution; (3) mucociliary and macrophage clearance; (4) absorption to lung tissue; (5) pulmonary tissue retention and tissue metabolism; and (6) absorptive drug clearance to the systemic perfusion. In this review, we describe these pharmacokinetic processes and explain how they may be influenced by drug-, formulation- and device-, and patient-related factors. Furthermore, we highlight the complex interplay between these processes and describe, using the examples of inhaled albuterol, fluticasone propionate, budesonide, and olodaterol, how various sequential or parallel pulmonary processes should be considered in order to comprehend the pulmonary fate of inhaled drugs. Inhalation therapy has gained importance in recent decades . Today, The primary goal of inhalation therapy for local treatment is to reduce pulmonary symptoms, for example, through the alleviation and/or prevention of airway inflammation and constriction . TypicalIt is typically assumed that the concentration of a drug at its site of action determines efficacy. In the case of inhaled drugs for local treatment, this should mean that pulmonary concentrations drive efficacy. However, it is important to highlight that the lung should not be considered as a single, uniform organ; rather, it is an intricate organ with fine, branched architecture, and various specialized morphologic structures, including conducting airways, bronchioles, and alveoli , 15. DueThis review provides a detailed overview of the factors affecting drug inhalation and discusses both the specific pulmonary and systemic PK properties of inhaled drugs that ensure optimal performance. In addition, we will summarize important clinical examples  that clearly demonstrate the complex interplay between pulmonary PK processes and factors related to the drug, formulation and device, and patients.Traditional methods of administration, such as the oral and intravenous (IV) routes, have distinct PK considerations. Oral drugs must pass through the gastrointestinal tract, the portal vein, and the liver prior to absorption into the systemic circulation. Therefore, the rate and extent of absorption is initially influenced by the dissolution kinetics and the solubility in gastrointestinal fluid. After dissolution, the intestinal metabolism, passive permeability, and transporter affinity (efflux/active uptake) of the drug determine the uptake across the intestinal membrane. Last but not least, the transport in the portal vein, as well as metabolic and transporter capacity in hepatocytes, determines the systemic bioavailability of orally administered drugs (hepatic first pass) . In contThe pulmonary PK processes after drug inhalation contrast to those following systemic administration and comprise (1) drug particle or droplet deposition; (2) drug dissolution in the lung fluids; (3) mucociliary clearance in the conducting airways and macrophage clearance in the alveolar space; (4) absorption (of dissolved drug) to the lung tissue; (5) pulmonary tissue retention and potential pulmonary metabolism; and (6) absorptive drug clearance (drug transport) from the lung tissue to the systemic perfusion. The interplay between these processes is outlined in As summarized in µm have the greatest potential to be deposited in the lung , thus maximizing the lung dose and the proportion of particles that are successfully delivered to their target site , 8923, 8Olodaterol is another inhaled drug reported to have interesting PK characteristics in patients. The impact of asthma and COPD on the pulmonary PK characteristics of olodaterol was evaluated in a population PK analysis. Here, despite the decreased lung function in asthma and COPD patients, pulmonary bioavailable fractions of inhaled olodaterol were comparable with healthy volunteers . AlthougInhaled drugs are the mainstay of treatment in the care of pulmonary diseases such as asthma and COPD –4. Compa


China has recently made efforts to integrate urban and rural basic medical insurance systems in order to ensure both urban and rural enrollees obtain unified benefits. However, whether the distribution of government healthcare subsides has become more equitable remains unknown. The purpose of this study was to analyze determinants of and inequality in net inpatient care benefits under the integration of urban-rural medical insurance systems in China.Data were obtained from a nationally representative household survey, the Fifth National Health Services Survey (2013), conducted in Anhui province. A multiple regression model and concentration index (CI) was used to estimate related factors and inequality of inpatient care net benefits.Findings indicated that individuals received more inpatient care benefits when urban and rural social healthcare systems were integrated. Factors associated with net benefits included gender, age, marital status, retirement, educational level, history of chronic diseases, health status, willingness to seek inpatient care and per capita income. The rich were found to disproportionately benefit from inpatient care, and the CI of net benefits for integrated insurance enrollees was the lowest among all three available health insurance schemes. These findings indicate that the recent unification of urban-rural social health insurances reduces inequality in net benefits from government subsidies. Some socioeconomic factors, such as per capita income, 60 years of age and over, history of chronic disease and high educational level positively influence inequality.In China, accelerating the integration of urban and rural medical insurance systems is an effective way to increase equity of benefit in urban and rural areas. Strategies aimed at reducing inpatient benefit inequality must address socioeconomic factors influencing healthcare outcomes. Achieving universal health coverage(UHC) which provides all individuals and communities with quality health services they need while sparing financial hardship, is one of the important targets of the Sustainable Development Goals set forth by the United Nations in 2015 . As the While China’s basic medical insurance has made great achievements, its framework highlights a few inherent structural problems. The long-standing urban-rural split in social health insurance systems, which not only hinders urban-rural integration but also causes inequality in government subsidies, is a major issue yet to be resolved. China has been making efforts to integrate URBMI and NRCMS thereby providing urban and rural residents with a unified coverage range, financing mechanism, benefits package, and fund management since 2012 . This prSome studies have reported that expansion of health insurance coverage increases access to benefits and healthcare utilization among the poor , 10. ExtAs China faces dramatic increases in healthcare costs, the social health insurance fund plays an increasingly significant role in reducing the financial barrier to healthcare access for all citizens . As healAlthough the Chinese health insurance system for urban and rural residents has been established for over 10 years and several prior studies have examined NRCMS or URBMI, few studies have focused on the integration of the new urban-rural medical insurance system. Furthermore, to our knowledge, there has been no research on the analysis of inequality in government healthcare subsidy distribution among people enrolled in URRBMI in China. Therefore, the aim of the present study was to analyze determinants and inequalities in net benefits of inpatient care under the integrated Chinese urban-rural insurance system and compare outcomes of URBMI, NRCMS and URRBMI enrollees. Using Fifth National Health Service Survey data, we estimated the impact related socioeconomic factors exerted on net benefits of inpatient care received under the urban-rural scheme. We then applied the concentration index (CI) and its decomposition to measure inequalities in the net benefits of inpatient care and estimate influences individual factors exerted on inequality.This study used data from the Fifth National Health Services Survey (NHSS) in Anhui province conducted in 2013. NHSS was conducted by the Statistics Information Center of the Ministry of Public Health, adopting the multi-phase stratified cluster random sampling method, and aimed to construct a high-quality nationally representative sample of the Chinese population. The NHSS has been conducted every 5 years and the 2013 survey was the fifth such survey. As the designated investigation team, we conducted the related survey in Anhui province. It should be noted that the 2013 survey data is the latest data of NHSS available at present. Anhui province, located in east China, is a major agricultural province with a large population . Data frNHSS data provides detailed information concerning individuals’ demographic characteristics, economic status, health status, healthcare utilization and costs, healthcare insurance status, distance to medical facilities and willingness to seek medical services. Information about all subjects was collected by household questionnaires and each eligible member of selected households was interviewed by the trained interviewers. Statistical analyses were performed with STATA 14.0.In our analyses, reimbursement received from NRCMS, URBMI or URRBMI was considered a measure of net benefit. The reimbursement ratio or reimbursement amount reflected the actual use of social health insurances, namely, for purposes of studying the distribution of insurance benefits from the perspective of result fairness . The depBased on related literatures, independent variables concerning demographic characteristics included age, gender, marital status, educational level and employment status . Economik as factors related to NB. The multiple linear regression model was defined as follows:Multiple regression was applied to identify determinants of net benefit. Here, we define xk denotes demographic characteristics, economic status and other related factors, wherein per capita income is also denoted with log values to avoid data nonstationarity.where Y represents NB  of inpatient care. xIn order to reflect net benefit inequality of inpatient care, we used a concentration index (CI) which is commonly used to measure socioeconomic-related health inequality –31. The h denotes the healthcare sector variable; μ is its mean; and r is the fractional rank of individuals in distribution of economic status. Here, CI is defined as the distribution of net benefit of inpatient care contributions across the population as ranked by per capita income. Individuals are sorting in ascending order of per capita income and are grouped into five income quintiles. The CI is positive if the net benefit distribution is progressive, suggesting that the rich receive more reimbursements than the poor. The value of CI is negative if the distribution of net benefit is regressive. And the value is zero, implying the absolute fairness. Furthermore, if the positive value is larger, the pro-rich pattern is more significant. If the absolute value of negative CI is higher, it means that the pro-poor pattern is more significant.Where Concentration index may be decomposed into individual factors contributions to net benefit inequality, where each contribution is the product of the sensitivity of net benefit with respect to that factor and the degree of inequality in that factor . Furtherβk is the coefficient of multivariate linear regression in eq. 1; k; CIk is the concentration index for xk; and GCI ε is the generalized concentration index of the error term ε.where Table Table Table Table Although the preliminary framework of a unified Chinese medical urban-rural insurance scheme has been implemented, it remains of great importance to explore the benefit distribution of government healthcare subsidies throughout the medical insurance system. To the best of our knowledge, this study, which was conducted using representative Chinese household survey data, is the first to examine and compare the inequality of inpatient care benefits among enrollees of three medical insurance schemes under the integration of social health insurance for urban and rural residents.In this study, we found that the amount of net benefits of inpatient care among URRBMI, NRCMS and URBMI enrollees ranked the greatest, the second greatest, and the least, respectively. This suggests that individuals receive more benefits under an integrated urban-rural insurance scheme. Factors associated with a net benefit of inpatient care received by rural and urban residents included gender, age, marital status, retirement, educational level, a history of chronic diseases, health status, willingness to seek inpatient care and per capita income. Females and those over 60 years of age received a significantly greater absolute amount of reimbursements for inpatient care, which is more significantly in NRCMS. These findings indicate that the elderly and females are main beneficiaries of net benefits, especially in rural areas. Divorced, single or separated individuals received significantly less reimbursements, indicating that marriage and family life are economically and spiritually positive factors in the effective utilization of available healthcare options. People with a higher education received more net benefits, in agreement with existing literature . Higher This study reveals a disproportionate concentration of inpatient care benefits among richer individuals and demonstrates that the rich received a greater amount of benefits than did the poor, in agreement with prior studies , 32. In Policies aimed at increasing the benefit equality must address socioeconomic factors affecting healthcare outcomes. Specifically, strategies should be implemented to increase welfare subsidies and perfect social assistance schemes that improve the precision assistance for the poor and relieve the economic burden of diseases. Social health insurance programs should be further adjusted to focus on the disadvantaged, such as those over 60 years of age, enduring poor economic conditions or suffering from chronic diseases, increase reimbursement levels, and expand benefit packages. In addition, according to our findings, accelerating the integration of urban-rural medical insurance schemes should be an effective way to increase equity of benefit in both urban and rural areas. In addition, strategies preventing and controlling chronic diseases and improving health equity may be further strengthened to alleviate the inequality of benefit distribution. With regard to individuals with NRCMS, improving a two-way referral system and encouraging the rich to attend primary care hospitals for healthcare may further reduce benefit inequality. The unequal benefit package for members of different schemes and the lack of alignment between provider payment mechanisms for referral care is also the common challenge those countries where multiple health insurance funds have been established to achieve universal coverage face .The findings of this study may provide evidence on increasing the benefit equality of health insurances for those countries where multiple health insurance funds have been established, especially some developing countries with a huge gap between urban and rural area. Some limitations of our study must be acknowledged. Firstly, we only adopted the Anhui province data from NHSS, potentially affecting finding universality and data representativeness. In addition, we only compared net benefit inequalities of inpatient care among different medical insurance programs but did not compare the same sample prior to and after insurance scheme reform. Furthermore, cross-sectional data did not allow for casual conclusions to be drawn. As the urban-rural insurance scheme integration progresses, further research is required to evaluate for any improvements in equality of benefit distribution.Individuals received more benefits for inpatient care under the integrated urban-rural health insurance scheme. Some socioeconomic factors such as gender, age, marital status, retirement, education level, history of chronic diseases, health status, and willingness to seek inpatient care and per capita income significantly affect net benefits received by individuals and reveal differences between health insurance schemes. Although a disproportionate concentration of net inpatient care benefits among the rich was observed, inequality of benefit distribution of URRBMI enrollees was less than that of NRCMS and URBMI participants, suggesting that the integration of urban-rural insurance schemes reduces net benefit distribution inequality. Per capita income, age over 60, a history of chronic diseases and high education level are major positive contributors to inequality. Expedited urban-rural insurance scheme integration and strategies focusing on socioeconomic factors will be effective methods for increasing fairness of health insurance benefit distribution.


Similar to other post-conflict nations in Southeast Asia, impacts of civil wars and violence, coupled with the present poverty, place older Cambodians in vulnerable health conditions. Older Cambodians have limited access to basic healthcare and decent living conditions. To date, little research has been conducted to understand their health and related determinants. This study aimed to examine the influence of economic wellbeing and the moderating effect of social engagement on the physical health of older Cambodians. Data came from Survey of Elderly Cambodia (2004), the only existing nationally representative dataset of older Cambodians age 60 and above . Economic wellbeing was measured in two dimensions: (1) subjective economic wellbeing with three indicators of self-rated economic satisfaction and (2) objective economic wellbeing with household item possession and current housing conditions. Social engagement was examined with four types of engagement in the community. For physical health, the number of health complaints was examined. Results of Poisson regression showed objective economic wellbeing, such as access to basic household items and decent housing conditions, was significantly related to physical health (p < .001). However, we found no role of social engagement in the association between the subjective economic wellbeing and health. Furthermore, social engagement has a significant moderating effect on the association between objective economic wellbeing and physical health (p < .001), controlling for all covariates. For anti-poverty and health policy development for older Cambodians, a promising intervention effort may focus on the ways to facilitate social engagement in later years.


Background and objective: Previous studies did not draw a definitive conclusion about the influence of the role of deep endometriosis (DE) and ovarian endometrioma (OE) as risk factor for developing adverse perinatal outcomes in patients affected by endometriosis. This study aimed to investigate if adverse fetal and maternal outcomes, and in particular the incidence of small for gestational age (SGA) infants, are different in pregnant women with OE versus pregnant women with DE without OE. Material and methods: This study was based on a retrospective analysis of a database collected prospectively. The population included in the study was divided into three groups: patients with OE, patients with DE without concomitant OE, and patients without endometriosis (controls). The controls were matched on the basis of age and parity. Demographic data at baseline and pregnancy outcomes were recorded. Results: There was no statistically significant difference in first trimester levels of PAPP-A, first and mid-pregnancy trimester mean Uterine Artery Doppler pulsatile index, estimated fetal weight centile, and SGA fetuses’ prevalence for patients with OE, and those with DE without OE in comparison to health women; moreover, there was no statistically significant difference with regard to SGA birth prevalence, prevalence of preeclampsia, and five-minute Apgar score between these three groups. Conclusions: The specific presence of OE or DE in pregnant women does not seem to be associated with an increased risk of delivering an SGA infant. These data seem to suggest that patients with endometriosis should be treated in pregnancy as the general population, thus not needing a closer monitoring. Endometriosis is a chronic estrogen-dependent gynecologic disorder affecting at least 3.6% of women of reproductive age . Pro-infDue to these abnormalities, endometriosis has been associated with defective deep placentation and several obstetrics adverse outcomes . In the Our academic group recently demonstrated that the presence of diffuse adenomyosis in women with endometriosis was more strongly associated with impaired placentation and delivery of SGA infants in comparison to patients with only endometriosis and with focal adenomyosis and concomitant endometriosis ; notablyHowever, despite this background, the role of each endometriotic phenotypes, in particular ovarian endometrioma (OE) and deep endometriosis (DE), as specific risk factor for developing adverse perinatal outcomes in women with endometriosis, has been not yet investigated. This study aimed to investigate if perinatal and maternal outcomes, particularly with regard to prevalence of SGA infants, are different in pregnant women with OE versus those with DE without OE.This study was done by performing a retrospective analysis of a prospective database collected between January 2017 and June 2018. Women included in the study signed a general consent form for using their clinical data for scientific purposes. The research on humans has been performed by respecting of all the relevant national regulations and institutional policies, in accord to the tenets of the Helsinki Declaration. This study was approved by the Regional Ethic Committee .Pregnant women with ultrasonographic diagnosis of endometriosis prior to conception were included. The ultrasonographic assessment was performed at any phase of the menstrual cycle regardless of the administration of hormonal treatment (estroprogestins and progestins). Standardized ultrasonographic criteria were employed for the diagnosis of DE  and OE ; in partThe patients were divided into three groups: women with OE, women with DE without OE, and women without endometriosis (controls). The controls were matched on the basis of age and parity. The controls were selected as the first patient who delivered at our institution, had no prior diagnosis of endometriosis and no symptoms suggestive of this disease , and had the same range of age of the cases with endometriosis .Women with previous ultrasonographic diagnosis of uterine adenomyosis , with chIn the first pregnancy-trimester, the measure of crown–rump length (CRL) was used for dating pregnancies according to the NICE  guidelines . At the GE Voluson E6  was employed for all the ultrasonographic assessments. At the first study visit, baseline maternal characteristics, including age, ethnic origin, and body mass index (BMI) were recorded. The maternal and neonatal outcomes of each pregnancy were collected. Delivery or follow-up scans were arranged as appropriate for any suboptimal assessments.Gestational complications were defined with standardized criteria: pregnancy induced hypertension (PIH), detecting after 20 gestation weeks a blood pressure persistently over 140/90 mmHg in a woman with previously normal pressure values; preeclampsia, in case of gestational hypertension and concomitant proteinuria (>300 mg/24 h); preterm birth, indicating a delivery before the completion of 37 gestation weeks; and SGA, in case of an infant with birth weight less than the 10th centile for gestational age.P < 0.05 was considered statistically significant. Appropriate statistical software  was employed for the statistical data analysis.The Kolmogorov–Smirnov test of normality was used for assessing the distribution of data, which were expressed as mean (SD), or median and interquartile range as appropriate. Categorical variables were described as number (%). The correlations between continuous variables were evaluated by Pearson coefficient or by Spearman rho and those between categorical variables were evaluated by Pearson ×2 test. Continuous variables were compared by Mann–Whitney and independent t-tests. Mean UtA Doppler PI, estimated fetal weight (EFW) centiles, and z-scores were calculated by using appropriate previously described reference ranges . Mean UtThere was no statistically significant difference in the baseline data within the three study groups. Overall, 160 pregnant women had complete follow-up, as required for being eligible for the study analysis; within this population, 40 (25%) had OE, 40 (25%) had DE, and 80 (50%) had no endometriosis.A statistically significant difference was not observed in the first trimester levels of PAPP-A, first trimester and mid-pregnancy mean UtA Doppler PI, EFW centile, and prevalence of SGA fetuses between patients presenting with OE and healthy women; moreover, no statistically significant difference was found in the prevalence of preeclampsia, SGA infants, and five-minute Apgar score between these two groups . MoreoveThe correlation between maternal and pregnancy specific characteristics with SGA and OE and DE was done by logistic regression analysis; p = 0.578) nor the presence of DE  were associated with the occurrence of SGA infants, after adjusting the results for potential confounding variables . Thus, these data seem to not support a potential causative link between these endometriotic phenotypes and impaired placentation and subsequent development of SGA births.The results obtained from this study demonstrate that the presence of OE or DE in pregnant women is not associated with an increased risk of delivering SGA infants. During the scan assessment in the 3rd trimester of pregnancy, the prevalence of SGA infants was similar within the three study groups ; similar results were observed for the prevalence of SGA infants at birth . When assessed singularly, conventional risk factors for placental insufficiency, such as BMI, PAPP-A, and mean UtA Doppler PI in first and the second trimesters of pregnancy, did not demonstrate a significant correlation with the presence of OE or DE. More importantly, logistic regression analysis showed that either the presence of OE  not detected by ultrasonography; in contrast, it seems unlikely that OEs were not diagnosed by ultrasonography in the DE group. Similarly, the presence of superficial peritoneal endometriosis in the control group cannot be excluded. However, considering that endometriosis has a low prevalence (about 4%) in the general population [A strength of this observational study is that patients with OE and DE without OE were separately studied in subgroups and compared to women without endometriosis; this has been done in order to better understand the impact of each phenotype of endometriosis on specific adverse pregnancy outcomes, and in particular on delivering SGA infants. Moreover, patients who conceived by ART procedures were excluded, thus eliminating the potential bias related to higher prevalence of adverse pregnancy outcomes, such as in cases of preeclampsia.The current study shows that the presence of OE and DE without OE are not risk factors of delivering an SGA infant. Thus, patients affected by endometriosis should be treated during pregnancy as the general population, not needing closer monitoring.


Malawi is a landlocked country with a population of 17 million. The delivery of the health care system is based on primary health care (PHC). The PHC structures are acceptable; however, the system is marked by maldistribution of resources, fragmentation of services and shortage of staff. This hampers the function of the set, well-meaning PHC frameworks. Family medicine offers training and retention of the PHC and rural workforce, harnessing clinical governance and capacity building. Family medicine’s role extends to involve advocacy for the PHC to improve its performance. It had an estimated population of 17.4 million people in 2017 with an average annual growth rate of 2.7%, giving an estimated population of 20.4 million people by 2022.7 The country’s GDP per capita in 2015 was estimated at USD381.40 and a growth rate was reported as 2.9% in 2016.8 Malawi’s GDP is one of the lowest in sub-Saharan Africa.9Malawi’s economy is largely based on agriculture, fishing and forestry, which contributes 28% of the gross domestic product (GDP).2 The following governmental departments provide public services: the Ministry of Health (MOH), district, town and city councils, Ministry of Defence and Ministry of Internal Affairs and Public Security (Police and Prisons).10 These departments work in collaboration with the MOH; however respective funding is planned and disbursed individually.Health services in Malawi are provided by the public, private for profit (PFP) and private not for profit (PNFP) sectors.The PFP sector is small, but growing, and includes an array of private hospitals and clinics that range from group to solo practices. Except for a few larger organisations, most PFP facilities are rudimentary, lacking adequate coordination and regulation. PFP entities are usually solo practices that are staffed by clinical officers or general practitioners. Mostly, PFP sector offers curative services with minimal laboratory support. Another important component of our health care system is the traditional healers and birth attendants who would be considered part of the PFP sector.2 Most PFP and PNFP services charge user fees. Government, through the ministry of health (MOH), enters into different service level agreements with the PNFP sector to provide essential services, such as maternal and child health care, especially in rural and remote areas.2The PNFP sector comprises of religious institutions, non-governmental organisations (NGOs), statutory corporations and companies. The major religious providers are organised under the Christian Health Association of Malawi (CHAM) which provides approximately 29% of all health services.Public sector provision of health care is free and organised into three tiers, primary, secondary and tertiary levels.2There are four tertiary hospitals, which are expected to offer advanced, specialised care, but in reality 70% of services offered at the tertiary level are for conditions that should be treated at primary care or district hospitals. This is partly because of poor gatekeeping mechanisms at the lower tiers of care.2 Each district hospital has an array of 11 to 40 health centres in its drainage area. Some districts have an intermediary level of community hospitals that are with PFP and PFNP facilities. District hospitals serve populations ranging from 140 000 to 1400 000.8The 26 district hospitals are often rural and act as referral centres for the primary care facilities. District hospitals offer outpatient and inpatient services, surgical procedures like caesarean sections, herniorrhaphy and other emergency life-saving surgeries. District hospital bed capacity can reach up to 300.The primary care level includes health centres with their constituent clinics, dispensaries and village clinics. Health centres offer ambulatory and maternity services. Health centres are meant to serve an average population of 10 000 people; however, some urban facilities serve up to 237 000 people. Primary care facilities are meant to link with community-based services, although there is often fragmentation between facility-based curative and community-based preventive activities.2 Other cadres and allied health professionals, such as laboratory technicians and physiotherapists are scantly present at district hospitals and health centres.The team at district hospitals comprises of one–two doctors, 10–20 clinical officers  and medical assistants who have three and two years of clinical training, respectively.11 Despite the said planning, discordance between DHMT’s plans, and priorities with partners’ areas of focus is often observed. Furthermore, programmes’ implementation and financing is verticalised portraying minimal integration, with an unacceptably unbalanced amount of resources allocated for HIV-related activities.The district health management team (DHMT) operates from the district hospital and includes clinical, nursing, environmental and administrative arms. The DHMT plans, monitors and evaluates the district health care activities as a whole.Health centres are staffed by nurses and medical assistants or clinical officers (mid-level practitioners). Nurses deal largely with primary maternal and child health services. Teamwork at health centre level between clinical, nursing and environmental staffs exists, but only to an extent. There exists a fair amount of dichotomy in implementation, monitoring and evaluation of the respective activities.7 HSAs mainly provide health promotion and preventive health care through door-to-door visitations and outreach clinics.7 The clinician and nursing roles at the health centre are largely curative, with minimal health promotion and preventive responsibilities. Most of the said roles are taken by environmental staff (HSAs) and CHWs. This dichotomy is seen, for example, during outbreak management or immunisation campaigns, where HSAs take most of the responsibility. CHWs are community volunteers who receive no formal training and act as a conduit for community engagement with the local community leaders and health advisory committees.The community links with the primary care facility are via a team of health surveillance assistants (HSAs), community health workers (CHWs) and traditional healers. HSAs are a community level cadre who received six weeks of initial health preservice training and ideally reside in the community they serve. Each HSA is responsible for about 1500 people, and there are currently about 11 000 HSAs in government service.7 Within the community, HSA’s work through the village leadership and CHWs as a team. With current efforts on decentralisation, efforts are being invested to harness community involvement to collectively contribute towards solutions to improve primary care outcomes.In the community, HSAs are seen as ‘doctors’. Their roles extend from sanitation, health promotion and community diagnosis to treatment of minor illnesses, especially in hard to reach areas as part of an integrated management of childhood illnesses programme.4 Other areas, for example, maternal health, still require innovation and further effort.Malawi made significant strides in meeting the millennium development goals for literacy, childhood mortality, HIV and malaria.11 The progress of this reform, however, has been thwarted by lack of capacity and resources at the decentralised platforms to carry out their respective duties.10Malawi’s efforts to attain the sustainable development goals are seen in its attempts to address the World Health Organization (WHO)s six building blocks of health service delivery namely; human resources for health (HRH), infrastructure, medicines and technology, health financing, health information systems, leadership and governance. For example, Malawi has rolled out its decentralisation policy programme in an attempt to devolve health service governance to facilitate community ownership and participation for delivery of EHP.2 The capability of the primary health care sector to deliver this package needs to be strengthened and extended beyond access and coverage, and also for improvement of quality.Malawi has shown commitment to universal health coverage by extending its original essential health care package to include non-communicable diseases, and continues to be free to all Malawians within public and most PFNP sectors.12 Another contribution is that FM is committed to capacity building of the multidisciplinary teams within PHC as a whole.12Family medicine (FM) is a discipline that aims to train doctors with a versatile skill mix that enables provision of care that is holistic, continuous and coordinated across the life cycle and diverse group of patient conditions, extending care to their families and communities. The FM has aligned itself to the national agenda of strengthening primary health care services delivery and access at district health level and below. Thus, FM operates in the decentralised platforms, harnessing functional links between district hospitals and their primary care facilities, thereby transforming PHC at a number of areas. Some key areas are improving the quality of clinical governance, increased access to better quality of care, advocacy for better allocation of resources for PHC, training and retention of a more skilled rural workforce.4 For example, its celebrated achievements in reducing childhood mortality is largely because of investments in the extended immunisation programme, primary and community case management.Malawi’s disease burden and analytical profile of key determinants of health, along with its successes and failures, are to a greater extent embedded in the performance of its PHC.2 This highlights lack of equity in deployment policies. Additionally, there are high vacancy rates (up to 80%) across all levels, but more so for senior medical officer positions.2 These factors impede the delivery of a ‘would have been good’ primary health care model.Theoretically, Malawi has reasonable PHC structures. However, in practice, the health system is marked by lack of resources, maldistribution of staff and funding between rural and urban settings and across tiers of care. Additionally, demotivated staff, task shifting and lack of good interdisciplinary models of work thwart implementation progress. An example of maldistribution of resources is evidenced in staff deployment where 50% of doctors and nurses are stationed in the four central hospitals.7 in practice PHC delivery remains fragmented and community participation is poorly coordinated.Whilst Malawi strives to base its health service delivery on the principles of PHC with community participation as a central approach in addressing health needs of its people,11 Some of the barriers to providing quality primary health care have been a lack of resources and capital investments, poor human resource deployment policies, funding models that do not favour PHC prioritisation, as well as poor coordination and integration of services.The current PHC structure with decentralised governance platforms and community involvement seeks to support PHC by expanding access to all levels of care. However, there are other determinants of access like cultural barriers and poor quality of services which need to be tackled from a multisectoral approach.Continued government commitment towards PHC is a big investment to health and is commended. It is not clear though to what extent this commitment and prioritisation of PHC is communicated among local and external partners within the health sector. This is evidenced by the substantial resources that are allocated to strengthening vertical programmes that hardly support PHC delivery as an entity. It is well known that health care provision in Malawi is highly dependent on external financing. Local and international partners’ budgetary and service support to districts and health centres ought to be coordinated in pursuit of priority district health goals. This requires high-levelled political commitment and support if we are to improve cost-effectiveness and achieve quality. The Health Sector Strategic Plan (HSSP) II has, therefore, focussed on strengthening governance of the health sector in order to improve efficiency and get the maximum out of existing human, financial and material resources. Family medicine has situated itself at the heart of the decentralised platform to help improve PHC functioning and capacity building.Putting infrastructure in place for PHC and improving access is not enough. Countries need to invest in improving the quality of primary care, integrating facility and community-based teams, and strengthening community participation. The multidisciplinary team may also benefit from the inclusion of family physicians.


It is common for patients with cancers in Hong Kong seeking Chinese Medicine (CM) therapies as supportive care during cancer treatment and to manage treatment-related side effects. This article provides clinical practice guideline (CPG) on the use of CM for specific clinical indications caused by cancer and during cancer treatment, including pain, constipation, and insomnia, and aims to guide local licensed CM practitioners and provide beneficial reference for social medical decision makers and patients. In this manuscript, we summarize the clinical manifestation, CM pattern classification, and CM intervention including herbal treatment, acupuncture treatment, regulating, and nursing based on pattern differentiation. According to the most update statistics from the Hong Kong Government, in 2015, number of new cases of cancer in Hong Kong hit a historical high of 30,318 and 14,316 deaths which were attributable to cancers [Since CM is well known for its clinical effect in improving the quality of life of cancer patients, in 2014, the Hospital Authority (HA) has been commissioned by the Hong Kong Government to launch a project named “Integrated Chinese-Western Medicine Pilot Programme” . EligiblUnlike other clinical guideline recommendations suggested to be used as the standard of therapy, we use the term “recommendation” to conclude CM treatments should be considered as a viable but not singular option for the management of a specific CM pattern. As CM contributes tailoring treatment based on symptom differentiation, combination-based approaches and the interactions of the numerous permutations are possible and still under investigating, such that recommendations must account for this limitation of our knowledge. Despite these limitations to evaluating the use of CM therapies in the oncology setting, the models provide sufficient evidence to warrant recommendations on the therapies as viable options for treating specific conditions.In this article, we introduce the formation, promotion, execution, and update of the CPG in brief and then provide background for each CM therapy that has a sufficiently large body of evidence and historical support to formulate the recommendations. Information is also provided for CM patterns diagnosis criteria and intervention details and to implement the recommendations into the different CM patterns, respectively, for cancer-related pain, constipation, and insomnia.The goal of this study is to summarize the methods and measures for the treatment of CM on pain, constipation and insomnia in cancer palliative care and to make a reasonable evaluation by careful review of existing practice and available published evidence on topic, in order to promote it and provide benefits for social medical decision makers and patients.※” and sources from Hong Kong experts' consensus are labeled by “§”. Levels of evidence and classes of recommendations are directly labeled after literature evidence.Data sources are labeled following by major content items. Sources from text mining are indicated by “This study was conducted according to our previous work . To avoiAfter retrieving data from SinoMed, we listed the data order by download order. In order to transfer the interesting data into the framework of structured file system, a tool has been developed (software copyright with submitted ID 0261882 and registered ID 2010SR073409) to transfer its plain TXT data into Microsoft® SQL Server® 2008 R2 Enterprise Edition. Then we use a data slicing algorithm “discrete derivatives” based on the calculation of frequency with detailed algorithm described in our previous research , to filtWith searching strategy, a combination of electronic and manual screening was adopted for systematic reviews of CM treatment on relevant symptoms. Cochrane guidelines were applied for methodological evaluation of literature quality. And we used the grades of recommendations and the levels of evidence proposed by Professor Jianping Liu of China designed for traditional medicines .On the key issues in the CPG, Delphi survey was applied to collect professional advice from licensed CM practitioners in Hong Kong based on the literature searching and documented clinical evidences. After 2 rounds of surveys, Hong Kong local experts obtained consensus opinions on the contents of the items which will serve as one of the main sources for the formation of CPG.Information from three aspects, (1) literature hotspots; (2) existing clinical evidence; (3) local expert consensus, is summarized and listed for optional items in CPG. Items with insufficient data support were excluded.A comprehensive review of the CPG was conducted through an expert consensus meeting and finalized the items for inclusion in the CPG.The guideline development group developed a framework and drafted the CPG accordingly.The electronic version of this study will be published on the official websites of the HA and the Hong Kong Registered Chinese Medicine Practitioners Association. Also, publicity and promotion efforts will be conducted to Hong Kong CM practitioners.It is the first time guidelines for CM clinical practice on cancer palliative care are formulated in Hong Kong. The production of this guide is just a beginning and an attempt. More experience and feedback are needed for further summarization.CPG development panel will regularly entrust relevant professional personnel to have review through collecting, collating, and analyzing newly emerged evidence. CPG development panel has the responsibility and rights for decisions on the revision. In general, the CPGs need to be revised or updated in the following cases: (1) to include new intervention methods; (2) to provide evidences prove that the existing intervention methods are the best, beneficial, or detrimental; (3) in adding new important or meaningful conclusions; (4) in generating new medical resources.Cancer pain is a subjective, multidimensional symptom that may affect patients throughout and after the course of the disease and its treatment . It is eConstipation is the third common symptom in palliative care cancer patients, only superseded by pain and anorexia –45. It iInsomnia is one of the most common symptoms experienced by cancer patients before, during and after cancer-related treatment with prevalence rates of 30%-70% –63. And CPG development panel consulted the patterns classification based on 1) literature hotspots; (2) existing clinical evidence; (3) local expert consensus and then determined 6 common CM patterns of cancer pain, 4 common CM patterns of cancer constipation, and 5 common CM patterns of cancer insomnia .According to the yin and yang sleep theory of CM, the yang qi rises during the daytime and reaches apex at noon. Combined with the understanding of modern time biology and clinical experience, it is recommended to follow a medicine taking approach stated by an ancient CM practitioner in Ming dynasty that insomnia patients are required to take the medicine one hour after lunch and one hour after dinner .Acupoints recommended for treatment of lung cancer pain are He Gu (LI4), Nei Guan (PC6), and Kong Zui (LU6), for treatment of liver cancer pain are He Gu (LI4), Nei Guan (PC6), Yang Ling Quan (GB34), and Zhong Du (LR6), and for treatment of intestinal cancer are He Gu (LI4), Nei Guan (PC6), Zhong Wan (RN12), Zu San Li (ST36), and Zhi Gou (SJ6) .Herbal dishes, static qigong, qigong exercise, ointment or medicinal oil for external use, bloodletting, auricular point (auricular beads), cold compress or hot compress, moxibustion, emotional counseling, sufficient sleep, etc. can be used to relieve cancer pain .Develop healthy eating habits, to eat mostly foods derived from vegetables, fruits, and whole grains, often to hydrate and limit spicy, highly fatty, or processed foods. Avoid excessive drinking or eating too much cold food. Strengthen regular physical exercise and avoid sedentary activities, develop regular bowel habits, avoid excessive mental stimulation, and maintain a pleasant mood. For elderly and chronic constipation patients, treating with enema or other external treatments can prevent spending a lot of time on the toilet straining which might induce acne, hematochezia, and even angina pectoris, myocardial infarction, or other symptoms  [In aspect of prevention, CM theory stated that insomnia is due to disorder of brain function. Therefore, it is important to promote a healthy brain and mind by maintaining pleasant mood and healthy work-life balance (grading of recommendation: BIa/IIIb) .※§; level of evidence: IIIb) [In aspect of nursing, it is to cooperate with CM practitioners in the treatment and care of elderly and disabled patients. Nursing includes basic care and specialist care. Basic nursing work includes daily life care, primary diagnosis and treatment techniques, daily observation, nutrition, disinfection and isolation, and hygiene, in order to establish proper environment to relief insomnia. There should be time for mind relaxing before going to sleep, avoiding spending time on worrying about falling asleep, and avoiding alcohol, caffeine, and nicotine. Appropriate relief exercises should be added after dinner. There is no tea or coffee before going to bed. Turn off the sound while sleeping, pull the curtains down, turn off the lights, and develop good sleep habits. Take Chinese Medicine on time to promptly treat related diseases. On sleep posture, generally, right lateral recumbent position is adopted while supine and prone positions should be avoided. In diet, take diet and health foods that promote sleep. Finally, methods such as medicine pillow, massage, and herbal dishes are also recommended for insomnia patients (grading of recommendation: Be: IIIb) .


OBJECTIVES/SPECIFIC AIMS: Despite the high prevalence of individuals diagnosed with sickle cell disease (SCD) in Tennessee, comprehensive care and education for patients with SCD is not as widely available as healthcare services for individuals managing other chronic illnesses. We aimed to engage SCD stakeholders in patient-centered outcomes research (PCOR) as a mechanism for advancing care and translational research for this rare disease population. METHODS/STUDY POPULATION: Through a partnership with the Sickle Cell Foundation of Tennessee, we implemented Community Health Ambassadors to systematically engage patient partners with SCD and their caregivers, aged 18–50 from rural and urban communities throughout Tennessee, in PCOR to establish a sustainable infrastructure, focused on connecting the SCD community through a service providing community-based organization to offer (1) information on how to connect with other families; and be informed about SCD community activities, or educational offerings; (2) training in basic research principals; and (3) opportunities to contribute to PCOR, including feedback on effective and practical ways for providing input on research efforts through patient centered input, comparing urban and rural area preferences. Community ambassadors utilized health fairs, clinic days at various hospitals and community centers, and social media to spread awareness of the project, in addition to boosting the recruitment process. RESULTS/ANTICIPATED RESULTS: A statewide SCD network was developed to offer social support and increase access to education, medical care, and engagement in research activities. Findings include: recruitment of 150 patients and 35 executive committee members . DISCUSSION/SIGNIFICANCE OF IMPACT: Most rural and urban families affected by SCD have no systematic way to engage in, or lend their expertise to, PCOR. A statewide network of patient partners, community stakeholders, researchers, and medical professionals will ultimately increase the standard of care for patients, and provide valuable insight for SCD research. The opportunity to create the underpinnings for coordinated patient-centered education for patients with SCD and their caregivers holds promise for developing a scalable PCOR process model for replication and implementation in other states and emulate this model with other rare disease populations.


World Health Organization (WHO) has created an essential list of in-vitro diagnostics. Supply chain management (SCM) is said to be the vehicle that ensures that developed point-of-care (POC) tests reach their targeted settings for use. We therefore, mapped evidence on SCM of and accessibility to POC testing (availability and use of POC tests) in low- and middle-income countries (LMICs).We conducted a systematic scoping review using Arksey and O’Malley’s framework as a guide. We searched PubMed; CINAHL; MEDLINE; WEB of Science; Science Direct; and Google Scholar databases for studies that focused on POC diagnostic tests and SCM. The review included studies that were undertaken in 140 countries defined by the World Bank as LMICs published up to August 2017. Two reviewers independently screened the abstracts and full articles against the eligibility criteria. The study used the mixed methods appraisal tool version 2011 to assess the risk of bias for the included studies. NVivo version 11 was employed to extract themes from all included studies and results presented using a narrative approach.p < 0.01). Nine studies underwent methodological quality appraisal and all, scored between 90 and 100%.Of 292 studies identified in this review, only 15 published between 2009 and 2017 included evidence on POC diagnostics and SCM. Of the 15 studies, three were conducted in Zambia, one each in Mozambique, Uganda, Guatemala; South Africa, one in Burkina Faso, Zimbabwe, and one multi-country study . Six studies were not country specific since they were not primary studies. Majority of the studies reported stock-outs of HIV, syphilis, and malaria POC tests. There was a moderate to substantial level of agreement between the reviewers’ responses at full article screening stage  contains supplementary material, which is available to authorized users. Access to accurate, safe and appropriate point-of-care (POC) testing is vital for routine care, early diseases, and monitoring of diseases . A POC dAccessibility to POC diagnostic services is dependent on many factors, including an efficiently managed SCM, which is agile, flexible and responsive , 9. EffiConsidering the potential challenges SCM could pose to accessibility of POC diagnostic services particularly in rural communities in LMICs, POC test availability and use, there is an urgent need to explore the role of SCM to help address supply chain barriers of POC diagnostic services in resource-limited settings and rural primary health care clinics. Therefore, this study aimed to map evidence on SCM of and accessibility to POC testing focusing on availability and use of POC tests in LMICs.We explored SCM and accessibility to POC testing using a scoping review methodology and adduced evidence on availability and use of POC tests in LMICs. A scoping study is useful and enables the identification of research gaps by mapping literature on a research question of interest as prescribed by the enhanced 2005 Arksey and O’Malley’s framework , 23. A sThe main review question was: What is the evidence on supply chain management and accessibility to POC testing services (availability and use) in LMICs?The sub review questions were as follows:What is the evidence on availability of POC tests in LMICs?What is the evidence on use of POC tests in LMICs?Population, Intervention, Comparison, and Outcome (PICO) framework was used to determine the eligibility of the primary research question as shown in Table We conducted a systematic literature search from the following databases: PubMed; EBSCOhost (CINAHL and MEDLINE); WEB of Science; Science Direct; and Google scholar. The database search occurred in June up to August 2017 using the following keywords: “diagnostics” “supply chain” “POC diagnostics” “supply chain management”  addressed all discrepancies at the full article screening stage.Evidence of POC diagnosticsEvidence of the study been conducted in a LMICEvidence of POC diagnostics productionEvidence of POC diagnostics selectionEvidence of POC diagnostics quantificationEvidence of POC diagnostics procurementEvidence of POC diagnostics storageEvidence of POC diagnostics distributionEvidence of POC diagnostics redistributionEvidence of POC diagnostics quality assuranceEvidence of POC diagnostics inventory managementEvidence of negotiation with suppliers for POC diagnostics supplyEvidence of safe disposal of used POC diagnostics productsEvidence of POC diagnostics accessibilityEvidence of POC diagnostics availabilityEvidence POC diagnostics useIncluded studies that met the following criteria:Lack of evidence of POC diagnosticsStudies conducted in high income countriesLaboratory based POC diagnosticsStudies that do not report on the primary outcomes of the studyA study was excluded if it did not meet the inclusion criteria. The exclusion criteria included the following:The selected studies were thoroughly read for data extraction of bibliographic details, aim/objective, study design, targeted population, intervention(s), relevant outcome(s), study setting, type(s) of POC diagnostics used, SCM interventions, and relevant outcomes of interest were extracted. Other information such as geographical location , country of the study, as well as, funding sources were also extracted. Data on country levels of income were obtained from The World Bank Group July, 2017 open data .We used the 2011 version of the mixed methods appraisal tool (MMAT)  to apprap < 0.01)  articles met the eligibility criteria following deletion of 22 duplicates from the total 314 articles identified at the title screening stage  of malaria RDTs use for testing children during follow-up visit . HasselbP < 0.001) for both midline and end line compared with the baseline [P < 0.001) and of 1.3% (P = 0.87) respectively [A research study conducted in Zambia showed increased syphilis testing during the early stages of RSTs introduction but subsequently dropped at the midline and end line . It demobaseline . Mabey ebaseline . It alsobaseline . Smith ebaseline . The stuectively . In all,ectively . This fiThairu et al. (2011) focused on describing lessons learned in providing CD4 diagnostics in Burkina Faso and Zimbabwe . The stuWe conducted a systematic scoping review of studies to explore evidence on supply chain management of and accessibility to POC testing, focusing on availability and use of POC tests in LMICs. The results demonstrated limited published research on SCM of and accessibility to POC testing in LMICs. It also revealed stock-outs of HIV, syphilis, and malaria POC tests. This study findings further demonstrated limited use of malaria RDTs, blood pressure, diabetes, and dyslipidaemia assays, low testing of HBV, and low repeated CD4 testing due to test stock-outs.Our study findings suggested quantification and forecasting, procurement, inventory management, distribution systems, quality management systems, and human resource capacity played a key role on the availability and use of POC test. Availability of adequate quality POC diagnostic tests essentially increases access to POC testing and improved healthcare. Despite this, evidence from this study showed weak procurement, inventory and stock management, and human resource capacity for SCM resulted in test stock-outs as well as, declined use of RST , 51, 54.The first WHO model list of essential in-vitro diagnostics (EDL) has been created . The WHOMajority of the studies reviewed were conducted in a rural setting where access to healthcare and laboratory infrastructure is either not available or poorly developed coupled with lack/inadequate skilled healthcare professional , 47–51. Our study shows that there is limited published research specific to SCM for POC diagnostics in LMICs, indicating a gap in literature. Our study findings also have international implications since the included studies were from diverse different countries. We hope this study will prompt further studies to provide a contextual insight on SCM for POC diagnostics bearing in mind the need to improve access for POC diagnostics services in LMICs. We further recommend a study to determine the impact of POC test stock-outs on patient outcome.This scoping review possibly is the first comprehensive study to map evidence on SCM and accessibility to diagnostic services at POC in LMICs. This study demonstrated a substantial gap in literature on POC tests SCM to guide future research in LMICs. This study’s methodology also allowed the inclusion of different study designs and identification of relevant articles methodically, charting, and analysing the outcomes , 69. TheIn conclusion, this study demonstrated limited published research on SCM of and accessibility to POC testing in LMICs. SCM play an essential role on the availability and use of POC tests as well as improved access to healthcare in resource-limited settings. Hence, it is worthwhile to consider SCM as a key component of POC diagnostic service implementation at the planning stages to ensure sustainability. We therefore, recommend primary studies aimed at investigating SCM of POC diagnostic tests in resource-limited settings to identify the barriers/challenges, and provide a context-specific evidence-based solutions for policy/decision makers, implementers, and POC developers, funders, and development partners.Additional file 1:Electronic databases search results for title screening. (DOCX 14 kb)Additional file 2:Full articles screening results and output of degree of agreement in Stata Version 13. (DOCX 16 kb)


The aim of this study was to evaluate the family impacts of severe dental caries among children. Data from 3859 school-age children  who participated in the 2013 Children’s Dental Health Survey, a national cross-sectional survey in England, Wales and Northern Ireland, were used. Severe dental caries was defined as having at least one tooth with pulpal involvement, ulceration, fistula, or abscess (PUFA). Family impacts were measured using seven items of the Family Impact Scale (FIS). The association between severe dental caries and family impacts was assessed in logistic regression models, adjusting for child’s age, gender, and country of residence; parent’s marital status, education, and job classification; and area deprivation. Severe dental caries among children showed a significant negative impact on family life . Parents of children with severe dental caries had greater odds of taking time off work , reporting the child needed more attention , feeling guilty , feeling stressed , having normal activities disrupted , and having sleep disrupted . Having severe dental caries was not associated with financial difficulties in the family . The observed association between severe dental caries and family impacts was independent of child and family sociodemographic characteristics. The findings underscore the importance of preventive interventions to avoid severe dental caries in children and subsequently reduce negative impacts on their family life.  Dental caries is the most common oral condition in childhood ,2. The WMost epidemiological surveys around the world use a standard method for caries assessment , which iChildhood dental caries, when left untreated, is usually associated with dental pain and inability to eat or sleep ,15,16,17This study was based on secondary analysis of the 2013 Children’s Dental Health Survey (CDHS). The survey protocol was approved by the ethics committee at University College London (ID: 2000/003). Written consent was provided by parents, but children could opt out at the time of the examination.The 2013 CDHS is a nationally representative cross-sectional survey of 5-, 8-, 12- and 15-year-old children in England, Wales, and Northern Ireland. Participants were recruited via multi-stage stratified sampling. Information was collected via parental questionnaires and child dental examinations. The number of participants in the survey who had clinical assessment was 2549 5-year-olds, 2367 8-year-olds, 2532 12-year-olds, and 2418 15-year-olds . Of the The outcome variable in this study was the family impacts related to children’s oral health. The survey assessed the impacts on family life using items from the 14-item Family Impact Scale (FIS)  of the PSevere dental caries was the main exposure, which was determined during clinical examinations and recorded as the number of teeth with pulp involvement, ulceration, fistula, or abscess (PUFA). Each clinical finding was recorded into 3 groups: 0, 1, and 2 or more lesions. A dichotomous variable indicating whether the child had any tooth with PUFA was created. Clinical examinations were conducted by 75 dentists, who were trained and calibrated in 8 groups. Intra-examiner reliability for tooth condition was high  .The analysis included several child and family characteristics that might confound the association between severe dental caries and family impacts. Child characteristics were gender, age  and country of residence . Family characteristics were the parent’s marital status , education  and job classification , and the quintile of deprivation of the residence area (based on the household’s postcode) according to the index of multiple deprivation (IMD).All analyses were conducted using Stata 15 . To account for the complexity of the survey, parent’s questionnaire weights and survey features (stratification and clustering) were used throughout the analysis. We first compared the prevalence of severe dental caries by child and family sociodemographic characteristics with the Chi-squared test. The association between severe dental caries among children and any impacts on family life was tested in logistic regression models. Odds ratios (OR) were the associational measure reported. They were adjusted for child demographic characteristics  and family sociodemographic characteristics . Separate regression models were also reported for the association between severe dental caries and each of the seven FIS items . The interaction between child gender and age was added to each regression model for statistical testing. The conventional significance level of 0.05 was used for hypothesis testing.p < 0.05 in all cases). Therefore, it was not included in the final models reported. The results from the adjusted regression models for each of the seven items on family impact are shown in This study assessed the family impacts of severe dental caries, indicated by any tooth with PUFA, among schoolchildren in the UK. The findings demonstrated that severe dental caries was related to negative impacts on family life. The strongest impacts of any child’s severe dental caries were related to parents feeling guilty and being stressed because of the child’s dental problem. Given the parents’ responsibilities for the child’s wellbeing, it is not surprising that perceptions of guilt and stress were the greatest implications of a child experiencing severe dental caries associated with pain and infection. Furthermore, the findings indicate that the presence of teeth diagnosed with PUFA among children can adversely impact family life by restricting their normal activities, causing them to take time off work, and disturbing their sleep, as they had to care for a child in pain. These findings are consistent with earlier research, which demonstrated an association between childhood caries and negative family impacts ,24,25,26The negative impacts of children’s severe dental caries on family life were higher among those with lower socioeconomic positions, particularly the least educated, manual or routine occupations, and living in deprived areas. However, after accounting for severe dental caries and other demographic factors, there were no statistically significant associations between socioeconomic indicators and family impacts. The only exception was for unemployed parents who had a great adverse financial impact due to children’s oral health problems. This could be attributed to the additional financial burden imposed on these families with lower income as they are trying to seek help for a child suffering severe dental caries . SimilarSevere dental caries indicated by the presence of pulpal involvement and periapical infection is more common in low-income countries . HoweverThe current analysis has the advantage of using data from a nationally representative sample for England, Wales and Northern Ireland. However, there are a few limitations worth mentioning. Firstly, the cross-sectional nature of the survey does not support inference on causality or temporality between severe dental caries and family impacts. Secondly, selection bias could have arisen from two sources, either because some families did not return the parental questionnaire or because they did not answer all questions. However, the analytical weights for the parental questionnaire data were used to compensate for this limitation and make the findings generalizable to the full study population. Furthermore, there were no major sociodemographic differences between children in our study sample and those excluded because of missing data on relevant variables. Thirdly, our assessment of family impacts was prone to measurement bias because it included only seven of the 14 items in the FIS. Such misclassification of outcome is likely to be non-differential , and therefore will tend to attenuate the association between severe dental caries and family impacts in the study sample. That said, the findings observed by specific FIS items do not share this limitation and provided richer information on the specific family activities that were disrupted. Severe dental caries among children had a significant negative impact on family life, most notably on parental perceptions of stress and guilt, interruption of normal family activities, sleep disturbance and missing working days. The relationship between severe dental caries and family impacts was independent of child demographic characteristics and family socioeconomic factors.


The Gulf Coast contains some of the most important shorebird habitats in North America. This area encompasses a diverse mixture of estuarine and barrier island habitats with varying amounts of freshwater swamps and marshes, bottomland hardwood forests, and coastal prairie that has been largely altered for rice and crawfish production, temporary ponds, and river floodplain habitat. For the purposes of this review, discussion is confined to general patterns of shorebird abundance, distribution, and macro- and microhabitat use in natural coastal, estuarine, and barrier island habitats on the Gulf of Mexico Coast. The following geographic regions are considered: Northwestern Gulf (Rio Grande to Louisiana-Mississippi border), Northeastern Gulf (Mississippi to Florida Keys), and Mexico (Rio Grande to Cabo Catoche [Yucatan Strait]).Wintering and migrating shorebirds are most abundant along the Gulf Coast in Texas and Tamaulipas, particularly the Laguna Madre ecosystem. Other important areas are the Southwest Coast region of Florida and the area between Laguna Terminos and Puerto Progresso in Mexico. In general, relative abundances of shorebirds increase from north to south, and decrease south of the Tropic of Cancer (23° 27’ N). Based on bimonthly maximum counts within 5° latitudinal bands, the region between 25–30° N is used most heavily by wintering and spring migrating birds.Non-vegetated coastal wetland habitats associated with bays, inlets and lagoons, particularly tidal flats, and sandy beaches are the habitats that appear to be favored by wintering and migrating shorebirds. In general, these habitats tend to occur as habitat complexes that allow for movement between them in relation to tidal flooding of bay-shore habitats. This relationship is particularly important to Piping Plover and may be important to others.Although vegetated habitats are used by some species, they do not appear to attract large numbers of birds. This habitat is most widespread between the Texas-Louisiana border and the Florida Panhandle region, but it has not been studied extensively. Shorebird abundance and habitat use in this area need to be addressed.


The aim of the study was to analyze the prevalence of activities of daily living (ADL) difficulties among older Ghanaians and specifically how one ADL, toileting difficulty, predicts care and supports needs using the World Health Organization International Classification of Disability and Health framework (WHO-ICF). Toileting difficulty requiring upper extremity strength is among ADLs that can lead to functional loss of independence among older people globally. A sample of n=5,096 adults aged 50 years and older from the WHO Study on global AGEing and adult health (SAGE) Ghana Wave 1 was used to analyze difficulties with ADLs and toileting. Level of difficulty was assessed against 22 other functioning items from the interview. Out of the 22 functioning items, climbing one flight of stairs without resting was the most difficult activity to be completed by older Ghanaians, and difficulty eating being the least endorsed item. Toileting was ranked the 16th in terms of reported difficulty and was related to other ADLs. Logistics multivariate regression was used to analyze data. Including significant variables from the univariate analysis in parsimonious model based on WHO-ICF framework, age, self-report health, memory, bodily pain, short distance vision, stroke, neighborhood trust, toilet facility type, and religious meeting attendance, were significantly independently associated with toileting difficulty. Gender was significant at the univariate level but became insignificant after adjusting for body function and structural variables. Toileting difficulty was associated with factors across different components in the WHO-ICF making the WHO-ICF an appropriate tool for understanding health and disability.