Arachis hypogaea L.), a self-pollinated legume is an important crop cultivated in 24 million ha world over for extraction of edible oil and food uses. The kernels are rich in oil (48–50%) and protein (25–28%), and are source of several vitamins, minerals, antioxidants, biologically active polyphenols, flavonoids, and isoflavones. Improved varieties of groundnut with high yield potential were developed and released for cultivation world over. The improved varieties belong to different maturity durations and possess resistance to diseases, tolerance to drought, enhanced oil content, and improved quality traits for food uses. Conventional breeding procedures along with the tools for phenotyping were largely used in groundnut improvement programs. Mutations were used to induce variability and wide hybridization was attempted to tap variability from wild species. Low genetic variability has been a bottleneck for groundnut improvement. The vast potential of wild species, reservoir of new alleles remains under-utilized. Development of linkage maps of groundnut during the last decade was followed by identification of markers and quantitative trait loci for the target traits. Consequently, the last decade has witnessed the deployment of molecular breeding approaches to complement the ongoing groundnut improvement programs in USA, China, India, and Japan. The other potential advantages of molecular breeding are the feasibility to target multiple traits for improvement and provide tools to tap new alleles from wild species. The first groundnut variety developed through marker-assisted back-crossing is a root-knot nematode-resistant variety, NemaTAM in USA. The uptake of molecular breeding approaches in groundnut improvement programs by NARS partners in India and many African countries is slow or needs to be initiated in part due to inadequate infrastructure, high genotyping costs, and human capacities. Availability of draft genome sequence for diploid (AA and BB) and tetraploid, AABB genome species of Arachis in coming years is expected to bring low-cost genotyping to the groundnut community that will facilitate use of modern genetics and breeding approaches such as genome-wide association studies for trait mapping and genomic selection for crop improvement.Groundnut ( Figure 1). The projected demand of groundnut in Asia alone by 2020 is expected to be 1.6 times more than the level of production in 2000  and protein (25–28%) in the kernels. They provide 564 kcal of energy from 100 g of kernels . In addiin Niger .-1 of dry matter. Being a legume crop, groundnut helps in improving soil health and fertility by leaving behind N2 and organic matter in the soil.Over 60% of global groundnut production is crushed for extraction of oil for edible and industrial uses, while 40% is consumed in food uses and others , an annual herb belonging to the family Fabaceae (Leguminosae), is classified into two subspecies, subsp. fastigiata Waldron and subsp. hypogaea Krap. et. Rig. The subsp. fastigiata contains four botanical varieties, var. vulgaris, var. fastigiata, var. peruviana, and var. aequatoriana. The subsp. hypogaea contains two varieties, var. hypogaea and var. hirsuta. Each of these botanical types has different plant, pod, and seed characteristics (A. hypogaea and A. monticola) in Section Arachis, and certain species in Section Rhizomatosae, are diploid (2n = 2x = 20). The diploid progenitors, A. duranensis and A. ipaensis, contributed “AA” and “BB” genomes, respectively, to the cultivated groundnut , and fruit-set  Van Arx, early leaf spot (ELS) caused by Cercospora arachidicola Hori and rust caused by Puccinia arachidis Spegazzini are among the major foliar fungal diseases worldwide. Aflatoxins are potent carcinogen produced by Aspergillus spp. infection in seed forcing several countries to have strict regimes in place on permissible levels of aflatoxins in their imports. A. flavus is predominant species in Asia and Africa, while A. parasiticus is in the USA. Stem and pod rot, caused by Sclerotium rolfsii, is potential threat to groundnut production in many warm, humid areas, especially where irrigated groundnut cultivation is expanding. Groundnut is also a host to several virus diseases, but only a few of them are economically important – groundnut rosette disease (GRD) in Africa, peanut bud necrosis disease (PBND) in India, tomato spotted wilt virus (TSWV) in the USA, peanut stripe potyvirus (PStV) in East and South East Asia, peanut stem necrosis disease (PSND) in pockets in Southern India, and peanut clump virus disease (PCVD) in West Africa , several species of thrips , leaf miner (Aproaerema modicella), red hairy caterpillar , jassids (Empoasca kerri and E. fabae), and Spodoptera are the major insect pests in groundnut, among which aphids, thrips, and Spodoptera have worldwide distribution and cause serious damage (Caryedon serratus) and rust-red flour beetle (Tribolium castaneum) are the major storage insect pests in groundnut. In most breeding programs across the world, breeding for resistance to diseases has received more attention than breeding for resistance to insect pest except when they are vector of viral disease. Another important reason for this is the availability of the resistant sources for diseases in cultivated and wild Arachis species.Groundnut is attacked by several diseases caused by fungi. Late leaf spot (LLS) caused by t Africa . Bacteriroundnut . Aphids s damage . In addivia micronutrient-dense crops) as a cost-effective and sustainable approach to fight malnutrition among poor. Development of groundnut cultivars suitable to mechanization is important in developed countries and it is also becoming important in developing countries where human labor for agricultural operation is not available or expensive. Some of the traits for such cultivars include strong pegs, uniform maturity of pods, break resistant pods, non-protruding radicle, and less erect plants with pods near the tap root. Biological nitrogen fixation (BNF) is another important target trait in groundnut that can be improved through both, cultivar selection and Rhizobium strain improvement.Quality includes both, physical and chemical attributes. Nutritional traits include oil, protein, sugar, iron and zinc content, fatty acid profile, and freedom from toxins, while the other quality parameters include visual and sensory attributes (consumer and trader preferred traits) and traits desirable in food/oil processing industries. Breeding for quality parameters in addition to yield enhances the economic returns to the farmers and other stakeholders along the value chain. Studies have shown that high oil content in groundnut is translated into economic benefits to both farmer and millers. Similarly, the produce with desirable traits for confectionary uses fetches higher price in the market because of its export value. Traits impacting on food and oil uses are also important; they include both quality and nutritional parameters. Depending on the nature of use, low oil and high protein contents (for food use), high oil content (for oil use), and high oleic/linoleic fatty acid ratio (for longer shelf-life) are important targeted traits in advanced breeding programs. The traits for confectionary uses in India are: greater proportion of sound mature kernels (SMK), flavor, 100 seed weight exceeding 55 g, >11% of sugar content, >24% of protein content, blanchability (>60%), and low oil content <45%; . Seed maArachis species are diploid except A. monticola and certain species in Section Rhizomatosae. The low genetic variability for the traits of importance and polyploidy nature are a bottleneck to the groundnut improvement. The cultivated accession of Arachis hypogaea in the genebanks (repositories of plant genetic resources) and the advanced breeding lines in the breeding programs are the most frequently used sources of variability used as parents in hybridization. Groundnut genetic resources are available in the genebanks of ICRISAT, National Bureau of Plant Genetic Resources (NBPGR), and Directorate of Groundnut Research (DGR) in India; Oil Crops Research Institute of Chinese Academy of Agricultural Sciences and Crops Research Institute of Guangdong Academy of Agricultural Sciences in China; U. S. Department of Agriculture, Texas A&M University, and North Carolina State University in the USA; EMBRAPA - CENARGEN and the Instituto Agronômico de Campinas in Brazil; and Instituto Nacional de Tecnología Agropecuaria (INTA) and Instituto de Botánica del Nordeste (IBONE) in Argentina. Selection of an appropriate source that can be used as a parent in hybridization is challenging for two reasons; first adequate variability should be available to identify a source and second, the amenability of trait for improvement that is determined by the genetic nature of the trait. Much of the variability till remains poorly used in improvement programs. The genetic variability in groundnut is low due to origin of the crop through a single hybridization event between two diploid species followed by a chromosome doubling and crossing barriers with wild diploid species (due of ploidy differences). The cultivated groundnut is an allotetraploid, while all wild Table 1). The germplasm accessions of cultivated groundnut in the gene banks are a vast repository of this variation. Wild Arachis species are also reported to possess desirable alleles for several economically important traits such as resistance to fungal and virus diseases, insect pests, and abiotic stress  lag between hybridizing two parents and identification of an improved breeding line for release as variety.A. hypogaea genetic resources is being exploited through the above breeding procedures to develop improved groundnut cultivars. But utilization of variability from wild Arachis species has been limited due to reproductive isolation of the cultivated species, A. hypogaea, an allotetraploid, from its diploid wild species due to ploidy differences and sterility. Wide hybridization has been used to harness the potential alleles from wild species and this yielding fruits with regards to resistance to disease. Despite attempts the vast potential variability of wild Arachis species still remains locked. Mutation breeding, using both physical and chemical mutagens has also been extensively used in groundnut breeding to induce variability that has resulted in development of several improved varieties. By 1996 in China, 15% of new groundnut varieties were bred from induced mutants and they accounted for 19.5% of the cumulative cultivated area in the country  on the other. For instance, our experience in foliar fungal disease screening nursery has shown that the rust pathogen, being obligate in nature, fails to establish and survive on leaf tissues that are already dead following leaf spot pathogen infection. As a consequence the plants infected with LLS pathogen will record low levels of rust infection and may get selected although the reason of low infection is other than resistance in this case. Another major pitfall in phenotyping is the proportion of chance escapes that get selected and hence the reliability and reproducibility are critical for a phenotyping procedure.A. flavus contamination in the field and reaction to soil-borne diseases need to be further developed to improve their repeatability. Similar is the case for phenotyping tools for reaction to insect pests. If surrogates for complex traits are found, they could be exploited for phenotyping of complex traits. Currently available phenotyping techniques for important target traits of groundnut breeding have been described by Table 2.Phenotyping for qualitative traits, inherited by few major genes is relatively easy. Phenotyping tools are extensively used by breeders in collaboration with plant pathologists, physiologists, entomologists, biochemists, and food technologists for selection and advancement of breeding populations and evaluation of advanced breeding lines. The technique that is reproducible, robust, cost-effective, and non-destructive  is desirable for phenotyping as breeding programs in general have large number of segregating generations and advanced breeding lines to screen. Phenotyping for reaction to diseases includes screening under artificial inoculation in the laboratory, green house, and in field and under natural disease pressure at hot spot locations . Either Following the breeding procedures and using various techniques of phenotyping, several improved groundnut varieties were developed and released for cultivation world over. Since 1986, national partners in 36 countries have released 136 improved ICRISAT-bred varieties in their respective counties. Some of the varieties are released in more than one country. The national programs in India have released 189 improved groundnut varieties for cultivation in the country. The genetic gain for yield in India came from improvement in seed size, seed weight, and number of pods per plant . From thJL 24, a popular short-duration groundnut cultivar in India, is a selection made from genotype EC 94943 introduced from Taiwan at the Oilseeds Research Station, Jalgaon, Maharashtra. It was released as JL 24 (Phule Pragati) in 1979 for cultivation in India . SubsequFollowing extensive screening of 5000 breeding lines and germplasm in wilt-sick plots in China and Indonesia, many genotypes with varying levels of resistance have been identified and using them bacterial wilt resistant cultivars were released in China, Indonesia, and other South East Asian countries that have offered protection against losses caused by the disease . At ICRIA. hypogaea from wild diploid species, A. cardenasii  was 133% for cultivation of large-seeded confectionary varieties, Asha (ICGV 86564) and Namnama (ICGV 90320) in the Philippines . Asha anvia selection of the genomic region harboring major QTLs for that trait; (2) Through molecular markers it is also possible to reduce the burden of linkage drag when the desirable traits are attempted to transfer from wild species or their derivatives into improved varieties. Systematic introgression of entire genome of a wild species into cultivated background is also possible by use of molecular markers, which is referred to as genome-wide introgression (GWI). Following this approach, it is possible to develop chromosome segment substitution lines (CSSLs) and advanced back-cross (AB)-QTL (AB-QTL) mapping populations which enable tapping of new alleles from wild species  It provides tools to target traits of economic importance that remained poorly/not amenable to conventional breeding approaches in part due to their quantitative nature of inheritance and presence of high g × e. The identification of genomic regions, popularly called QTLs for quantitative traits is now routine, and thus it is possible to achieve genetic gains through selection for quantitative traits  species . More deMarker-assisted back-crossing has been the most preferred and result oriented molecular breeding approach for improving existing popular genotype for one or two traits and pyramiding of few genes/QTLs. Most importantly, MABC is now in routine use in development of near-isogenic lines (NILs) or CSSLs for genomics research. The limitation of this approach is its inability to handle multiple traits/QTLs/genes in one attempt due to requirement of large back-cross populations which becomes unmanageable . Since, Before the linkage maps were made available, bulk segregant analysis (BSA) was used to identify the linked markers for nematode resistance , aphid vDespite several possibilities to overcome the bottlenecks of conventional breeding and some demonstrated successes in other crops including groundnut, the uptake of molecular breeding approaches in groundnut improvement programs in developed countries is contrasting with that in developing countries such as India and African countries. This may in be in part due to lack of infrastructure, high cost of genotyping, and human capacities available in the developing countries. The progress made when molecular breeding was integrated with conventional procedures in development of improved groundnut varieties was quite impressive. rust01) contributing up to 82.96% phenotypic variation for rust resistance, it was introgressed through MABC to improve three popular groundnut varieties  for rust resistance using GPBD 4 as a donor genotype. Several promising introgression lines with remarkable reduction in disease spread and other desirable agronomic traits have been selected for further multiplication and generation advancement rams see . It is eBoth MABC and MARS requires development of family mapping populations and identification of QTLs/marker effects before getting into the main stages of improvement programs. Further due to difficulty in handling polygenic traits and sometimes in development of good mapping populations, a better approach called “genomic selection (GS)” is fast emerging as a molecular breeding approach for crop improvement. Identification of superior lines with higher breeding value  in segregating breeding populations based on genome-wide marker profile data is the first step toward using this approach. To do so, a training population (TP) comprised of elite breeding lines for which multiple-season phenotyping data on agronomically important traits are available across environments is required for estimating GEBVs. Parental genotypes are then selected based on GEBVs and crosses are effected to develop candidate population (CP). In other words, CP is developed from the crosses made using the lines with best GEBVs in the TP as parents . GS is nArachis species was also used to develop improved groundnut varieties. The breeding procedures used for self-pollinated crops are employed in groundnut improvement programs along with use of phenotyping tools. Identifying and assessing the nature of variability for target traits, utilizing the sources of variability as parents in hybridization, and advancing the best possible genotypes after selection are the key steps in the groundnut breeding programs. Pedigree, bulk-pedigree, and single seed decent methods are followed to handle segregating population after hybridizing two parents. Following conventional approaches, several improved groundnut varieties with high yield and tolerance/resistance to foliar fungal diseases, bacterial wilt, root-knot nematode, virus, rosette diseases, and drought were released for cultivation. The released varieties have a wide range of maturity duration, ranging between 90 and over 150 days required for cultivation in various growing regions with varying LGP. They belonged to different market types, viz, Spanish, Virginia, and Valencia and meet market uses (oil and food uses) and agro-climatic requirements.The conventional breeding approaches have largely utilized the available genetic variability in cultivated groundnut and to some extent the variability trapped in wild Arachis species that remain under-utilized. Targeting multiple traits (gene pyramiding) is another important possibility of molecular breeding approaches. Groundnut breeding programs in USA, China, India, and Japan have already embarked the new technology to complement the ongoing breeding programs. “NemaTAM” is the first cultivar developed through molecular breeding for resistance to root-knot nematode. This was followed by “Tifguard High O/L” that has high O/L ratio and multiple resistances. At ICRISAT, MABC is underway to develop cultivars with rust resistance that are now in advance generations and also pyramid resistance to rust and LLS. MABC for improvement of oil quality is underway at USA, Japan, and India. The uptake of molecular breeding tools in groundnut breeding programs in developed countries is contrasting with developing countries like India and African countries, which is in part due to inadequate infrastructure, high genotyping costs, and inadequate human capacities in the later. On the other hand, more efficient genomic tools are under development, and this is expected to happen more rapidly once the draft genome sequence is available.The last decade has witnessed development of molecular marker linkage maps in groundnut that was followed by identification of markers and QTLs for target traits. This paved way for deployment of molecular tools in breeding program for efficient utilization of time and resources and improved efficiency of breeding. As a consequence, the extensive breeding programs are becoming intensive with the use of molecular breeding tools. Marker technologies offer approaches (GWI and AB-QTL mapping) that enable tapping of new alleles from wild The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Community health assessment is a core function of public health departments, a standard for accreditation of public health departments, and a core competency for public health professionals. The Tennessee Department of Health developed a statewide initiative to improve the processes for engaging county health departments in assessing their community’s health status through the collection and analysis of secondary data. One aim of the Tennessee Department of Health was to position county public health departments as trusted leaders in providing population data and engaging community stakeholders in assessments. The Tennessee Department of Health’s Division of Policy, Planning, and Assessment conducted regional 2-day training workshops to explain and guide completion of computer spreadsheets on 12 health topics. Participants from 93 counties extracted data from multiple and diverse sources to quantify county demographics, health status, and resources and wrote problem statements based on the data examined. The workshops included additional staff development through integration of short lessons on data analysis, epidemiology, and social-behavior theory. Participants reported in post-workshop surveys higher degrees of comfort in interpreting data and writing about their findings on county health issues, and they shared their findings with health, hospital, school, and government leaders  in their counties. Completion of the assessments enabled counties and the Tennessee Department of Health to address performance-improvement goals and assist counties in preparing to meet public health accreditation prerequisites. The methods developed for using secondary data for community health assessment are Tennessee’s first-phase response to counties’ request for a statewide structure for conducting such assessments.  Community health assessment (CHA) is a long-standing core public health function  and is nThe Tennessee Department of Health (TDH) recognizes the necessity of understanding community health needs in a way that supports data-driven decision making at the county, regional, and state levels. Realizing the challenging environment of health care reform and resulting new demands on public health professionals, county and regional health department representatives requested in November 2011 that TDH leadership re-engage a statewide CHA. County health departments desired to reassert a leadership role in population-based assessment and use CHA results to develop action plans with local stakeholders. Because the most recent county-specific statewide assessment took place in the mid-1990s, county and state public health officials viewed this re-engagement as important to empower local leaders to identify and respond to today’s public health needs.The request for a statewide CHA dovetailed with a new departmental priority to promote organizational continuous improvement. TDH introduced the Baldrige Performance Excellence approach  in NovemAs an award recipient of the National Public Health Improvement Initiative (NPHII) Strengthening Public Health Infrastructure for Improved Health Outcomes  grant prThe primary goal of the CHA was to improve the processes, findings, and use of CHAs as a competency of county health departments in Tennessee. Objectives were —To develop a CHA tool that uses existing secondary data to produce consistent health information.To improve state assistance to counties by making population health data more accessible and understandable.To promote community benefits through shared findings with stakeholders to identify priorities for health improvement plans.To engage participants in a replicable, experiential learning approach, including collegial exchange, to improve statewide public health competency in assessment.To create an environment in which use of data is expected for planning, grant proposal writing, and program evaluation.To meet its objectives, TDH needed to design a CHA program that a range of county health department professionals  could complete quickly and easily. The program needed to consist of a single, standardized method, and it needed to be replicable to encourage future use. Lastly, the program needed to create an environment that encouraged participants to identify collaboratively common challenges, available resources, and opportunities for improvements. cancer. Workgroup members also submitted suggestions for useful data and websites that they had used in conducting their own assessment.First, staff from the Division of Policy, Planning and Assessment (PPA) formed a workgroup with members from 4 county health departments with previous experience in conducting a CHA . The worPlanning workgroup members from 4 county health departmentsEpidemiology and statistical staff from the Division of Policy, Planning and Assessment to access data and use technology to develop modulesContent experts from the Tennessee Department of Health programs to advise on module contentDeputy Commissioner for Continuous Improvement and Training as facultyParticipants from 93 county health departmentsNext, TDH’s leadership team and regional and metropolitan county health department directors reviewed the proposal for conducting a statewide CHA using secondary data. Leadership identified important aspects of the proposed assessment. The assessment would enable counties to collect, analyze, and present data and increase their awareness of differences and disparities between county, state, and national data indicators. The assessment would also empower county staffs to share findings with their county health councils (established in 1996 ) and to Working with 27 content experts from TDH, PPA staff led the process of module formulation and technical development beginning in April 2012. Content experts contributed topic-specific materials, including 1) sample learning objectives; 2) key topical issues of which each county should be aware; 3) relevant data indicators and websites; 4) types of locally available information on county resources and situations; 5) trigger questions about county data and comparisons with state and national data; and 6) supplemental information.PPA staff used this input to create 12 modules formatted in Microsoft Excel  . Staff iModules developed in Microsoft Excel Excel VBA  objects and formulas used to create interactive, multipage, interlinked applicationsHyperlinks to Web addresses and embedded Tennessee Department of Health reports led to dataSupplemental topical files provided in PDF attachmentsNon-Web–based data sources developed from Tennessee Department of Health business units and data systemsThree CHA workshops were conducted in June 2012, 1 each in the eastern, middle, and western regions of the state. This geographic distribution facilitated attendance, enabled interaction among peers from the same region, and reduced travel expenses. PPA staff coordinated logistics, including identifying locations with computer labs, preparing meeting materials, and arranging hotel accommodations. TDH Division of Local Health Services helped to recruit counties to attend the workshops. The deputy commissioner made presentations at regional county health councils meetings and promoted the CHA at Tennessee Public Health Association regional meetings.The first day of the workshop opened with a videotaped welcome by the commissioner of health, who indicated the importance of the CHA as part of organizational performance improvement. On the first day, participants completed the following modules: 1) demographics (introducing data used in subsequent modules); 2) local health department services; 3) risk factors (largely based on BRFSS data); 4) cancer; 5) diabetes; 6) heart disease and stroke; and 7) health disparities. The second day began with a summary and debriefing of modules covered during the first day. The state director of vital statistics presented “The Art of Data” to explain how to interpret data and ways to present data to support data-driven decision making. Next, participants completed the remaining modules: 8) access to care; 9) oral health and dental care; 10) mental health; 11) perinatal issues and infant mortality; and 12) child health. At the conclusion of the final module on the second day, participants wrote problem statements using data from the completed modules.A moderator introduced each module by using PowerPoint slides and describing the topic’s importance to the health of the state’s population. The deputy commissioner and PPA staff integrated basic epidemiologic concepts and health behavior theories as part of module introductions. Participants committed to share these findings with supervisors and county health councils on return to their counties. Participants left the workshop with paper copies of all modules and a USB flash drive containing their completed modules, supplemental topical information (readings and Web references), and supporting secondary data sets. PPA staff informed participants that they would follow up with them for evaluation purposes and that a CHA, consisting of more in-depth assessment methods, would start in fall 2012.In all, 93 of 95 counties participated in the workshops; participating counties completed 98% of all modules  and wrotThe pre-test identified frustration among participants with using secondary data. Participant concerns included limited access to timely county-specific data, the labor-intensive process of locating and extracting data, and difficulties in interpreting data. Participants also reported lack of awareness of many websites and TDH data resources. The post-test indicated that the most important workshop outcomes were that participants had learned where to find data, who to call at TDH, and how to interpret data. One participant stated, “We should look at the data, not just address the numbers that are being requested.” Pre-test to post-test comparisons indicated that comfort levels in working with data increased significantly by the end of the workshop .The pre- and post-test asked participants to state 3 ways their county’s health-related data differed from those for other counties and from those for the United States as a whole. In the post-test, 43% of participants changed all 3 responses from their pre-test, 23% changed 2 responses, and 21% changed 1 response; only 13% retained all 3 of the pre-test responses. The results demonstrate the influence of participants’ newly gained knowledge.After completing all modules, each participant wrote 4 problem statements based on county-specific data. We organized these problem statements into topics and dimensions and counted the frequency with which participants mentioned each topic . The 2 mThe 2007–2009 mortality rate  for children aged 1 to 4 in [East] County is almost 20% lower than the state rate of 32.6, whereas the 2007–2009 mortality rate  for children aged 15 to 18 in [East] County is almost 30% higher than the state rate of 66.9.The 2007–2009 mortality rate  for children aged 5 to 14 in [East] County is 304% higher than the state rate.From 2002 to 2006, the rate of emergency department visits for asthma among [Middle] County children (aged 1–17) was 1.5 times greater than the state rate for that group. Charges for inpatient hospitalizations related to asthma for children in the county were nearly twice the average charges for the state.Counties confirmed the community benefit of the CHA by sharing data and other findings with health, hospital, school, and government leaders in their counties. Ninety-five percent of counties responding to an evaluation administered 9 months after the workshops reported presenting their data to community stakeholders. More than 80% shared data with both county health department staff and community health councils. Half of the counties shared data with hospitals as part of the new CHA requirements for nonprofit hospitals. Counties also indicated that CHA data and problem statements were useful in their selection of a health topic for a new TDH requirement to develop a community-based primary prevention initiative. Participants reported the CHA was most helpful in improving a sense of competency in 3 areas: 1) identifying sources of public health data and information; 2) identifying the health status of populations and the related determinants of health and illness; and 3) adhering to ethical principles in the collection, maintenance, use, and dissemination of data and other information.The CHA process supported counties’ efforts to improve their essential public health services , addressed prerequisites to accreditation standards, and improved workforce competencies.Public health leaders contemplating a CHA that uses the Tennessee program as a template might consider some of the following observations. From a design perspective, imposing limitations on module content was necessary for developing a workshop that could be completed in 2 days. The 2-day time frame required PPA staff to be selective about which data to introduce to participants. Awareness of statewide and region-specific population health disparities, the degree of difficulty in extracting data from websites, and the desire for a statewide focus on TDH priority health issues also influenced data selection. Each module was designed as a completed product, which participants could repeat to further explore data. Workshop leaders clearly stated that the value of secondary data assessment was not to identify causal mechanisms for disease but rather to increase knowledge of the county’s health data and methods for obtaining additional data. A second phase of the CHA, planned for 2012–2013, will introduce community-interactive qualitative assessment methods to clarify causal factors for selected health issues.Module content and layout was the most time-consuming part of the development process. The program designers had to check methodically the correctness of all secondary data and website sources. Logical clustering of data points and potential responses to trigger questions in each module required careful scrutiny to ensure meaningful findings for participants. Likewise, the staff that created Excel spreadsheets with pre-formatted cells for data entry and automatic calculations of county-to-state or county-to-nation comparisons had to ensure that each cell functioned properly to guarantee a standardized, repeatable process. Designers created a second print page that was automatically populated with inputted and computed data. The modules are now a replicable tool through which counties can monitor population health changes over time for program planning and implementation purposes.That participants reported being significantly more comfortable with using data by the end of the workshop suggests they will also be more comfortable in using data for decision-making purposes. Multiple counties demonstrated this comfort by creating county fact sheets based on CHA data for communicating population health risks to community members and then engaging community members in planning, developing, and conducting successful population interventions.We identified 4 categories of implementation challenges: resource limitations, planning and preparation, facility limitations, and communication. Ensuring the availability of such resources as qualified, skilled personnel and computer access was pivotal for success. Developing a CHA approach to meet participants’ time limitations challenged the designers’ ability to balance teaching strategies and learning objectives. Allocating planning time for creating, developing, and testing the modules was also critical. The hands-on learning approach required simplicity in module design to accommodate an audience with varied skills. The choice of the training facility influenced participants’ interaction, an important component of group learning. Computer labs with appropriate software versions and Internet access  and a high level of communication among the many stakeholders were also required to ensure a successful program.Post-workshop evaluation identified several potential improvements for program development and implementation. The module development stage should use a standard project-management technique to assign time and tasks and allocate sufficient resources for module pre-tests. Designers should consider alternative methods for deciding which modules are developed and used. Workshop participants indicated that time allocated for introduction, module completion, and group debriefing was insufficient. Scheduling flexibility may be required for future workshops; for example, the program planners added a 1-hour pre-workshop session to upgrade participants’ basic computer skills, including skills used for Excel software and navigation of the Internet. A written agreement that specifies follow-up steps to encourage participants to use what they learn is another potential improvement; such an agreement would include a commitment to respond to a post-workshop evaluation, develop county fact sheets, and present data to local audiences.TDH recognizes CHA as fundamental to the delivery of multiple essential public health services . The Ten


Katherine Todrys and Joseph Amon argue for criminal justice system reforms in sub-Saharan Africa to reduce HIV and TB transmission in prisons and to guarantee detainees' human rights and health. HIV and tuberculosis (TB) prevalence in sub-Saharan Africa is higher in prison than in non-prison populations due, in part, to on-going transmission related to overcrowding and a lack of adequate prevention and treatment services.Almost all prisoners eventually leave prison and, along with visitors and prison officers, represent a potential bridge for disease transmission between prison and community populations.Thousands of individuals are detained in African prisons unjustly and unnecessarily, including spending long periods in pretrial detention, because of weak criminal justice systems.Alleviating overcrowding by increasing the availability of non-custodial alternatives including community service and bail, and improving access to legal representation, are essential public health measures for HIV and TB prevention and control in African prisons.African governments and international health donors should fund justice initiatives and other structural interventions to address HIV and TB in prisons and the general population in Africa.HIV prevalence in sub-Saharan African prisons has been estimated at two to 50 times that of non-prison populations Prison health care in Africa is under-resourced, and increased funding is needed to ensure adequate treatment is available, including antitretroviral (ART) therapy as treatment for HIV, and for HIV and TB prevention Prisons throughout sub-Saharan Africa are often filled far beyond their capacity. The prison populations in Burundi, Cote d'Ivoire, Kenya, Mali, Uganda, and Zambia are over 200% of capacity; in Benin, it is over three times design capacity . OvercroOne reason for overcrowding is extended pretrial detention. Half or more of the prison population consists of remanded prisoners (who have not been convicted) in Angola, Benin, Burundi, Cameroon, Chad, Comoros, Congo, Liberia, Mali, Niger, Nigeria, Togo, Uganda, and Tanzania . LengthyThis policy proposal discusses how criminal justice system failures and limited financial resources present barriers to reducing HIV and TB transmission in prisons and how “structural rights” interventions focused upon criminal justice system reform are needed to guarantee detainees' human rights and health. To better understand structural barriers to HIV and TB prevention in African prisons, we conducted a survey of prison commissioners and medical directors in East and Southern African countries with high HIV and TB rates. Written surveys were sent via email, fax, or post to prison authorities in the 18 states that are members of the Southern African Development Community (SADC) and East African Community (EAC). Ten surveys were returned . Topics covered in the survey included size of the prison population; available health services; HIV and tuberculosis prevalence; mortality rates; donor and government funding for health services; and challenges in health care administration. Respondents were informed of the purpose of the survey and that information provided would be publicly reported. Consistent with the US Code of Federal Regulations, which exempts ethics review for surveys of elected or appointed public officials, independent ethics approval was not sought International law requires that individuals who are detained be brought “promptly” before a judge, and be charged or released Under Ugandan law, a suspect must be charged by a court within 48 hours of arrest Pretrial detention is routine, and even after an initial appearance, remandees are often held for years pending trial. In Uganda, the average wait is estimated at 1 year and 3 months for capital offences, such as defilement, murder, aggravated robbery, and rape Compounding these injustices is the fact that, in some cases, detentions are entirely arbitrary. In Zambia, for example, the police and the Drug Enforcement Commission enjoy broad powers under Zambian law and reportedly arrest and hold numerous alleged family members, friends, and by-standers as “co-conspirators” when their primary targets cannot be found Lack of non-custodial sentencing, restrictions on the use of parole, and delays in appeals further contribute to overcrowding. In Uganda, use of community service as an alternative to sentencing is increasing, but is inconsistently applied and highly dependent on the magistrate Nearly all African prison administrators in our survey cited inadequate funding as the most significant challenge to their ability to deliver health care. Prison authorities in Tanzania also cited insufficient numbers of qualified medical personnel; Swazi authorities cited poor infrastructure for health, as well as absence of a medical officer trained in HIV treatment; Zimbabwean authorities cited inadequate equipment, physical infrastructure, and training of health personnel in TB and HIV management; South African authorities cited shortages of health care professionals and lack of appropriate facilities for the management of communicable diseases; Malawian officials cited a shortage of medical equipment and drugs; and Mauritian prison authorities noted insufficient health staff. Furthermore, a recently published analysis found that, between 2003 and 2010, only one of the ten countries in the Southern African region and four of the ten countries in the East African region with Global Fund-supported TB programs included TB interventions within prison settings International human rights law requires that states maintain adequate prison conditions and provide a minimum level of health care to individuals in detention Treatment in community-based facilities is theoretically possible at some prisons; however, access to care is frequently controlled by medically untrained prison guards. Lack of adequate prison staff, transportation, and fuel for the transfer of sick prisoners, as well as security fears, keep inmates from accessing medical care outside of prisons, in some cases for weeks after they fall ill The promise of expanded ART “treatment as prevention” (TasP) approaches to impact community-level HIV transmission “Structural-rights” interventions Under Global Fund Round 8, Zambia was granted 3.7 billion kwacha  over 2 years for HIV prevention in prisons One approach could be to expand voluntary HIV counselling and testing. Some research has shown that people who know their HIV-positive status are more likely to change behavior Criminal justice system reform is not a panacea, of course. Factors other than overcrowding and pretrial detention also require attention. Inadequate nutrition is a cause of ill health among prisoners While nearly all prisoners return to the community, many serve multiple short sentences, cycling in and out of prison. Visitors and prison officers also link prisons to the community, bridging prison health and public health. Both increased resources for health, as well as structural interventions addressing criminal justice failures, are necessary to address HIV and TB and advance prisoner and public health. African governments have a responsibility to address the life-threatening conditions in prisons, which are contrary to international law and standards, and to improve prisoners' access to justice. Both African governments and international health donors should fund justice initiatives and other structural interventions to address HIV and TB in prisons and the general population in Africa.


AbstractMylabris of the nominate subgenus is described and figured. This species is apparently endemic to the south-eastern Iranian province of Kerman and seems to be phenetically very distinct from all other species of this subgenus, primarily because of the unique elytral pattern. A key to the species of the nominate subgenus distributed in Iran is also presented.A new species of  Meloidae of the Middle East remain poorly studied even though this area is one of the most interesting of the Palaearctic region from biogeographic and taxonomic points of view. Within the Middle East, the family is most speciose in Iran which harPageBreakbours a fauna with several endemics together with many species in common with Central Asia, Anatolia and Levant, as well as some Saharo-Sindian and Arabic components in the southern provinces. The descriptions of species and faunistic records concerning the blister beetles of this area are few and highly scattered in the literature. The only synthetic works on the Iranian Meloidae were published in the last century by Meloidae, listed 194 species for this country.The Meloidae of the subfamilies Nemognathinae and Meloinae. Unresolved taxonomic problems prevent all from being described at this time. However, we are taking this opportunity to describe one very distinct new Mylabris Fabricius, 1775 belonging to the nominate subgenus. It is endemic to a narrow area of Iran and represents the southeasternmost species of the nominate subgenus except for Mylabris quadripunctata  and Mylabris variabilis , which are broadly distributed from the Iberian peninsula to western China.The Hayk Mirzayans Insect Museum (HMIM) of the Iranian Research Institute of Plant Protection and the M. Bologna collection at the University Roma Tre (CB) house several new species of Iranian Mylabris is easily distinguished using a key published by Mylabris remains that published by Sumakov (1915). In order to help with the identification of the Iranian species of the subgenus Mylabris, we provide a key to its species recorded in Iran.The meloine genus urn:lsid:zoobank.org:act:0141DDB7-3BC1-49EC-A502-776A5004B625http://species-id.net/wiki/Mylabris_barezensisHolotype male (HMIM), and 2 males (CB) and 1 male and 2 female paratypes (HMIM), labelled “ Dehbakri, 6.5.1969, Paz.& Hasch.”.IRAN, Dehbakri ; an Iranian town in the Kerman province, about 55 km southwest of Bam, east of Jebal Barez mountain, at 2027 m a.s.l. This mountainous area was characterized by forest until before the second World War , along the external margin except at apex  in one  and withHead slightly longer than wide at temples level (excluding mandibles), wider at temples than at eyes; punctures relatively deep, large and irregular, surface among punctures shagreened, shiny on vertex, wrinkled on frons; head capsule subquadrate, temples broadly curved posteriorly and subequal in length to the longitudinal length of eye; frons flat, in the middle with one red spot more or less divided posteriorly; clypeus transverse, convex, with slightly rounded anterior and lateral margins, anteriorly depressed, fronto-clypeal suture clearly visible; labrum only slightly shorter and narrower than clypeus, anterior margin sinuate, longitudinally depressed in the middle; mandibles robust, curved, in lateral view longer than clypeus and labrum together; maxillary palpomere II with very long setae on the posterior side, last maxillary palpomere apically thickened and truncate at apex; antennae  extendinPageBreakPronotum slightly wider than long, narrowed anteriad, convex, without evident depressions or with a superficial rounded depression in the middle of each side, maximum width posterior to middle; punctures almost confluent on anterior and posterior third; elytral pattern as in piculum gastrale is variable: most males have this sclerite slender in the middle and clearly narrowed and elongate in the last portion . The nominate subgenus at present contains 19 species (The taxonomic revision of the nominate subgenus of  species , but at Mylabris barezensis. This species is clearly distinct from all others of the nominate subgenus by the unique elytral pattern, as well as by the mesosternal “scutum” with dense and very long setae.For this reason we are unable to discuss in detail the phylogenetic relationships of Mylabris barezensis is similar to two species of the subgenus Micrabris from Afghanistan, namely afghanica Kaszab, 1953 and marakensis badakhaskanica Kaszab, 1958 (both figured in Phenetically, Meloidae, as “Mylabris biguttata Gebler”, a species which actually belongs to the mylabrine genus Hycleus, but has a similar elytral pattern.PageBreakThe type specimens were previously identified by Zoltán Kaszab, the late Hungarian specialist of


Overall cancer incidence rates decreased in the most recent time period in both men and women, largely due to improvements in surgical therapeutic approaches (tertiary prevention) and screening programs (secondary prevention), but differences in cancer incidence and survival according to socioeconomic status are documented worldwide. Health risk behaviors, defined as habits or practices that increase an individual’s likelihood of harmful health outcomes, are thought to mediate such inequalities.Obesity has been related with increased cancer incidence and mortality due to imbalance of leptin and adiponectin which are connected to activation of PI3K, MAPK, and STAT3 pathways and decreasing insulin/insulin-like growth factor (IGF)-1 and mTOR signaling via activation of 5 AMP-activated protein kinase (AMPK), respectively. Physical activity has been associated to prevent cancer by the aforementioned obesity-related mechanisms, but also increasing level of circulating vitamin D, which has been related to lower risk of several cancers, and increasing prostaglandin F2a and reducing prostaglandin E2, which are both related with cancer prevention and promotion, respectively. A large number of different substances may induce themselves a direct cytotoxicity and mutagenic action on cells by smoking, whereas alcohol promote immune suppression, the delay of DNA repair, inhibition of the detoxification of carcinogens, the production of acetaldehyde, and the contribution to abnormal DNA methylation. The combined smoking and alcohol drinking habits have been shown to increase cancer risk by smoke action of increasing the acetaldehyde burden following alcohol consumption and alcohol action of enhancing the activation of various procarcinogens contained in tobacco smoke.Interventions at the social level may be done to increase awareness about cancer risks and promote changing in unhealthy behaviors. Cancer is a leading cause of death worldwide, accounting for 7.6 million deaths  . It has Obesity has dramatically increased during the last few decades both in developed and now also in developing countries, contributing to the global rising of cardiovascular diseases . NowadayObesity has been widely associated with non-communicable diseases, such as cardiovascular diseases (heart disease and stroke), diabetes, osteoarthritis and musculoskeletal disorders, fatty liver, gall stones, psychological disorders, and psychosocial problems  as well An inflammation theory for cancer development related to obesity has been also hypothesized. Indeed, the increased levels of proinflammatory cytokines and various interleukins related to body adiposity, may stimulate the activation of NF-κB complex which may promote cancer development itself .Hyperinsulinemia and elevated IGF-1 are related to the diabetic condition and the obese status. Both insulin and IGF-1 have been hypothesized to play a role on cancer promotion through the Akt/PI3K/mTOR cascade that promotes cell growth and proliferation ,48. On tObesity has been related also to decreased survival in patients affected by several types of cancers ,56 althoA protective association between physical activity and colon, breast, ovarian, lung, and renal cancers is supported by a number of review articles -67. SimiSeveral reports seem to demonstrate the detrimental effects of smoke on health, increasing risk of many cancers, including lung, laryngeal and pharyngeal, followed by upper digestive tract and oral cancers , as wellAlcohol has been reported to cause nearly 4% of the global cancer burden , and chrThe combined smoking and alcohol drinking habits have been shown to be detrimental for health and notably increase cancer risk by smoke action of increasing the acetaldehyde burden following alcohol consumption and alcohol action of enhancing the activation of various procarcinogens contained in tobacco smoke due to increased metabolic activation by an induced cytochrome P450-2E1-dependent microsomal biotransformation system in the mucosa of the upper digestive tract and the liver .The most recognized interventions on cancer prevention regard secondary prevention, such as screening programs. These interventions aim to diagnose the malignancies at an early stage and to treat these lesions before spread occurs. On the other hand, they do not interfere with factors which may play a role in the genesis and promotion of the disease. Primary prevention may reduce the exposure to cancer-promoting environmental and behavioral influences .A series of intervention through public health policy can be made in order to decrease cancer risk among general population. Regarding smoking habit, a six-point intervention list has been developed by the World Health Organization and focus on the following main features: monitor tobacco use and prevention policies; protect people from tobacco smoke; offer help to quit tobacco use; warn about the dangers of tobacco; enforce bans on tobacco advertising, promotion, and sponsorship; and raise taxes on tobacco . Public The authors declare that they have no competing interests.SR: conception and design, drafting the manuscript; GG, AM, SM, FN: drafting the manuscript; SB, FG, FB, SG, AB: critical revision, given final approval of the version to be published.


Violence and mobility have been identified as critical factors contributing to the spread of HIV worldwide. This study aimed to assess the independent and combined associations of mobility and violence with sexual risk behaviors and HIV, STI prevalence among female sex workers (FSWs) in India.Data were drawn from a cross-sectional, bio-behavioral survey conducted among 2042 FSWs across five districts of southern India in 2005–06. Regression models were used to estimate odds ratios and 95% confidence intervals (CIs) for sexual risk behaviors and HIV infection based on experience of violence and mobility after adjusting for socio-demographic and sex work related characteristics.One-fifth of FSWs (19%) reported experiencing violence; 68% reported travelling outside their current place of residence at least once in the past year and practicing sex work during their visit. Mobile FSWs were more likely to report violence compared to their counterparts . Approximately 1 in 5 tested positive for HIV. In adjusted models, FSWs reporting both mobility and violence as compared to their counterparts were more likely to be infected with HIV (Adjusted odds ratio (adjusted OR): 2.07, 95% CI: 1.42–3.03) and to report unprotected sex with occasional  and regular clients .The findings indicate that mobility and violence were independently associated with HIV infection. Notably, the combined effect of mobility and violence posed greater HIV risk than their independent effect. These results point to the need for the provision of an enabling environment and safe spaces for FSWs who are mobile, to augment existing efforts to reduce the spread of HIV/AIDS. Violence and mobility are increasingly being recognized as important risk factors contributing to the spread of HIV and sexually transmitted infection (STI) worldwide -11. HighIn addition to violence, recent research has identified employment-related mobility  as another major risk factor associated with HIV -10,19-23While studies have demonstrated the independent effect of mobility and experience of violence on FSWs’ sexual risk behaviors and STI, there is a paucity of literature on the combined relationship of mobility and violence on HIV risk behaviors, STI and HIV. This paper seeks to address this gap in the literature by examining: (a) the independent association between mobility for sex work and violence; and (b) the independent as well as the combined association of mobility for sex work and violence on risky sexual behaviors and STI, including HIV.Data were drawn from the Integrated Behavioral and Biological Assessment (IBBA), a cross-sectional survey conducted in 2005–06 among FSWs in eight high HIV prevalence districts of Andhra Pradesh state, India  . A probaOverall, 3271 FSWs completed the behavioral interview and provided biological (blood and urine) samples in Andhra Pradesh. Of the eight districts surveyed, data from three districts, namely Hyderabad, Karim Nagar and Warangal, were not included in the current analysis, as a different questionnaire was used in these districts, which did not include mobility-related questions; this resulted in an analytical sample of 2042 FSWs.Chlamydia trachomatis (chlamydia), Neisseria gonorrhea (gonorrhea), syphilis and Herpes Simplex Virus-type 2 (HSV–2). The testing procedures adopted in the survey have been described in detail elsewhere [Face-to-face interviews were conducted by trained field workers in the local language, Telugu, using a structured questionnaire that included questions on socio-demographic characteristics, sexual behavior, mobility and experience of violence. Interviews were conducted in locations previously hired for data collection purposes; respondents were escorted by members of the field team from solicitation sites to the interview location. In addition, biological samples were tested for HIV and other STI, including lsewhere .Ethical clearances were obtained prior to the survey. Statutory approval for conducting the IBBA and its protocols was obtained from the Government of India’s Health Ministry Screening Committee. A comprehensive consent process was adopted: respondents were first informed in detail about all aspects of the survey, following which oral consent was separately obtained for the behavioral and biological components.dhaba, bar/night club and lodge; and public place including park, street, cinema hall, bus stand, railway station and vehicle), having a regular non-paying partner and client volume per week . Duration of sex work was computed by subtracting the respondent’s age at initiation of commercial sex from her age at the time of interview. Both socio-demographic and sex work related characteristics were used as covariates in the multivariate analyses.The socio-demographic characteristics of FSWs considered in this paper were based on single items in the questionnaire, which included age , literacy , marital status , alcohol consumption , primary place where clients were entertained  no violence and not mobile; (ii) no violence but mobile; (iii) violence but not mobile; and (iv) both violence and mobility.The dependent measures used in this paper were: sexual risk behaviors, STI and HIV infection. Sexual risk behaviors were measured using two key variables that determined FSWs’ unsafe sex behavior: (1) no condom use at most recent sex with occasional clients; and (2) no condom use at most recent sex with regular clients.Information on STI and HIV was based on the laboratory test results of biological samples. Participants were considered HIV-positive if their blood samples tested positive on the Microelisa test, and were confirmed by the Genedia HIV ½ ELISA 3.0 test. Participants were considered positive for chlamydia and gonorrhea if the infection was detected in their urine samples by the nucleic acid amplification test (NAAT). In this study, participants were considered to be infected with an STI if they were diagnosed with chlamydia or gonorrhea. The syphilis and HSV–2 test results were not included in the analysis as the syphilis test results may not reflect current infection and the HSV–2 test was conducted among only 10% of those who provided biological samples.Sample characteristics were assessed to identify the factors that differed by mobility status and experience of violence, using chi-square contingency tables. Logistic regression models were used to estimate odds ratios (OR) and corresponding 95% confidence intervals (CI) to analyze the relationship between reported violence, mobility for sex work, and sexual risk behaviors and STI including HIV. A series of multivariate logistic regression models were constructed to measure: (i) the association between mobility for sex work and violence and vice versa; (ii) the association between mobility for sex work and sexual risk behaviors, HIV and STI status; (iii) the association between violence and sexual risk behaviors, HIV and STI status; and (iv) the combined association of mobility for sex work and the experience of violence on sexual risk behaviors, HIV and STI status. Adjusted OR and CI are presented. Sampling weights were used to account for the differential recruitment of FSWs by typology within districts, differential probabilities of selection across districts and differential non-response rates. The weighting methodology has been described elsewhere . StatistOf the 2042 FSWs included in the analyses, one-fifth 19%) had experienced violence and two-thirds (68%) had travelled outside their current place of residence at least once in the past year and practiced sex work during their visit . Similarly, mobile FSWs who experienced violence were significantly more likely to report no condom use in their most recent sexual encounter with regular clients than non-mobile FSWs who did not experience violence .Results indicate that the experience of violence and mobility for sex work were independently associated with HIV infection Table . The oddOur findings indicate that a large percentage of FSWs travelled outside their current place of residence and practiced sex work during these visits, and nearly one-fifth experienced violence in this high HIV prevalence state of southern India; these results are similar to prior findings in India ,14,17. AConsistent with previous research, our study shows that mobile FSWs were more likely to be infected with HIV than those who were not mobile ,10,30. WThe current research also indicates that one-fifth of FSWs had experienced violence in the past year, and the experience of violence was higher in selected groups; for example, those who were previously married. Further, a higher proportion of FSWs who had experienced violence were infected with HIV than their counterparts; a finding that is consistent with previous research ,16. As dWhile there is growing recognition of the effect of mobility and violence individually on the health of FSWs, including their vulnerability to HIV ,7,33,34,While this study underlines the strong association between violence, mobility and the prevalence of HIV among FSWs, the results should be interpreted with caution in light of certain limitations. First, the key independent variables considered in this study were based on self-reported responses, and the limitations of self-reported data are widely recognized . MoreoveOur finding that mobile FSWs who have experienced violence are particularly vulnerable to HIV has significant implications for the design of HIV prevention programs. To reach FSWs with different vulnerabilities, interventions would need to implement strategies that recognize and address both issues of violence and mobility among FSWs. Moreover, intervention programs need to recognize that as mobile FSWs have recently moved to new places for sex work, they may be poorly informed about HIV prevention support and service programs in the new area, and additional efforts would be required to connect them to suitable local services, such as the availability of crisis response systems that provide appropriate information and timely services to address violence.In the context of the study finding that mobile FSWs who also experience violence are at greater risk of acquiring HIV than others, special efforts are needed to address the vulnerabilities of this subgroup of sex workers. Ongoing and future programs need to explore the ways in which they can improve accessibility to support structures and services for sex workers on the move. Additionally, the ongoing efforts of community mobilization ,41 need The author(s) declare that they have no competing interests.SR led conceptualization, conducted all analyses, and wrote the manuscript. DG assisted with writing and editing of the paper. BM and RMM assisted with the analyses. NS assisted with conceptualization of analytic approach and interpretation of study findings. All authors have read and approved this final submitted manuscript.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2458/12/764/prepub


Although public concern has focused on the environmental impact of the Deepwater Horizon oil spill, the public health impact on a broad range of coastal communities is minimally known.We sought to determine the acute level of distress , mechanisms of adjustment , and perceived risk in a community indirectly impacted by the oil spill and to identify the extent to which economic loss may explain these factors.n = 71, Franklin County, Florida) or directly exposed  to coastal oil. We also compared findings for participants who reported income stability (n = 47) versus spill-related income loss (n = 47).Using a community-based participatory model, we performed standardized assessments of psychological distress , coping, resilience, neurocognition, and perceived risk on residents of fishing communities who were indirectly impacted (We found no significant differences between community groups in terms of psychological distress, adjustment, neurocognition, or environmental worry. Residents of both communities displayed clinically significant depression and anxiety. Relative to those with stable incomes, participants with spill-related income loss had significantly worse scores on tension/anxiety, depression, fatigue, confusion, and total mood disturbance scales; had higher rates of depression; were less resilient; and were more likely to use behavioral disengagement as a coping strategy.Current estimates of human health impacts associated with the oil spill may underestimate the psychological impact in Gulf Coast communities that did not experience direct exposure to oil. Income loss after the spill may have a greater psychological health impact than the presence of oil on the immediately adjacent shoreline. The Deepwater Horizon oil platform explosion and spill on 20 April 2010 generated substantial concerns about the ecological impact on the U.S. Gulf Coast environment. For 5 months, almost 5 million barrels of oil spilled into the Gulf of Mexico, reaching > 600 miles of the Gulf Coast shoreline in Florida, Alabama, Louisiana, and Texas . It was Using a community-based participatory research model, our investigators worked with community agencies and leaders from two Gulf Coast fishing communities  to develop and implement a formal investigation of the acute psychological distress, neuropsychological baseline status, and personal resources for adjustment and adaptation of local residents. Extant data suggest that after disasters, mental health problems are most likely to appear after the acute crisis has abated see . HoweverBecause oil never reached Franklin County shores, effects of the disaster would have been indirect  but may have been significant nonetheless. Residents observed daily media reports about the spill, provided clean-up assistance in other Gulf communities, and actively engaged in protective environmental activities in anticipation of oil reaching their shores. Fears about seafood safety led to a dramatic reduction in local seafood harvesting, forcing layoffs in packing houses and transportation because of a lack of product.The potential for significant psychological sequelae after indirect exposure to oil spills and other environmental disasters has been well documented. These parallel the psychological distress associated with direct disaster exposure and include symptoms of depression, anxiety, and post-traumatic stress disorder (PTSD) . Three pThe most severe, lasting, and pervasive psychological effects are often found after disasters that engender serious and ongoing financial problems . Economia) to determine the acute level of psychological distress , mechanisms of adjustment , and perceived risk of individuals in a community who were indirectly impacted by the Deepwater Horizon oil spill disaster; and b) to determine whether participants who sustained economic loss as a result of the oil spill had greater evidence of psychological distress, reduced capacity for adjustment , and greater perceived risk than persons who were economically stable. We hypothesized that a) in Gulf coastal communities, the psychological distress , mechanisms of adjustment , and perceived risk  associated with indirect impact would be similar to that of direct exposure to the oil spill disaster; and that b) people with oil spill–related economic losses would have more psychological distress, have less resilience, be more likely to use maladaptive coping strategies, and report more risk concerns than those with economic stability during the oil spill crisis.Many factors impacting psychological reactivity after oil spills are potentially modifiable. With this in mind, our community–academic partnership was initiated to identify people at greatest risk for mental health problems for early public health intervention. The study objective was 2-fold: This study was undertaken as part of a larger ongoing effort being conducted by the University of Florida to assess the acute environmental and health impacts of the spill among persons living in fishing communities along the Florida and adjacent Alabama coast. Using a community-based participatory model, we developed and implemented the project in collaboration with local community and religious leaders, mental health coalitions, trade associations, and the University of Florida, Franklin County extension service. Our community partners also provided insight into measurement selection and adaptation, the interpretation of our findings, and recommendations for outreach and intervention.Study participants in Franklin County, Florida, included 71 adult volunteers with permanent residence in the county  who sustained an indirect impact or exposure to the oil spill. Indirect impact was defined as living in a community where oil did not reach the coastline but significantly impacted fishing and recreation/tourism economies and required reallocation of resources to protect their shellfish beds, wildlife, and other coastal resources. Recruitment was targeted toward adults (18–75 years of age) working in the fishing/seafood and tourism/service industries, as well as family members, recreational fishers or harvesters, and retirees who lived and recreated in the community. Persons were excluded if they had a neurologic or psychiatric condition that would preclude understanding the informed consent or examination procedures. Recruitment was through advertisement on the local radio station (Oyster Radio) and contacts with members of the local fishing industry though the University of Florida Extension Office.The direct exposure comparison group (persons living or working in a community where spilled oil reached the shoreline) included 23 participants from Baldwin County, Alabama . Our community partner in Bon Secour was the local office of the Alabama Seafood Association. Members (and families) of the association were contacted by telephone  and invited to participate in the study. Exclusion criteria were the same as the primary study group.a) previously established reliability and validity for the constructs they measure and the populations to which they were applied; b) ease of administration in the field; c) repeatability for prospective studies; and d) ability to assess the construct of interest with minimal participant burden. Participants were reimbursed $40.00 for study participation. We performed data analyses using the PASW Statistics Package 18 ; an alpha level of 0.05 was established as the cutoff for statistical significance.All study participants underwent all study procedures. The community partners identified exam locations that included three sites for the primary, indirect exposure study group  and one church for our comparison group. A team of three examiners, formally trained in psychological and neuropsychological assessment, administered the standardized cognitive and psychological interviews and procedures. The team included a licensed psychologist, who supervised two additional research assistants responsible for reading forms and paper-and-pencil measures to participants with literacy or vision difficulties. Written informed consent was obtained from all participants in compliance with all applicable U.S. requirements according to standard procedures required by the University of Maryland and the University of Florida institutional review boards. The examination procedures took approximately 90 min and included a standard interview and formal neuropsychological, psychosocial, and risk perception measures. All measures were selected based on Basic demographic, occupational, medical, psychiatric, and drug/alcohol history data were collected using a modified Boston Occupational and Environmental Neurology Questionnaire (BOENQ)  and BrieEconomic loss was determined for each participant based on their responses to the following two questions: Have you lost any income since the oil spill? . What has been the biggest impact of the oil spill? . Participants were assigned to the economic loss group if they indicated they lost income since the oil spill, the income loss was related to the oil spill, and the biggest impact of the oil spill on their life was economic.The neuropsychological battery evaluated neurocognitive functions within the context of possible exposure to oil and chemical dispersants. Cognitive impairments or associated exposures, if they exist, can potentially confound the assessment and interpretation of the psychological and behavioral variables of interest. The neuropsychological screening battery consisted of tests from the World Health Organization Neurobehavioral Core Test Battery, which has been recommended for use in studies of neurotoxin exposures . This tet-scores  referencing an adult, normative database provided in the manual (We used the Profile of Mood States (POMS)  to assese manual . With the manual  to idente manual . It is sCoping strategies are used to describe the way people respond to stress. In this investigation, we studied the coping strategies people used during the oil spill. Coping was assessed using the Brief COPE questionnaire . The que“Resilience” refers to the ability to bounce back from adversity; for the purpose of this study, “resilience” is operationally defined by responses on the Connor-Davidson Resilience Scale  (rt form) . The CD-rt form) . The meart form) .Several questions or questionnaires have been developed and used to measure perceived risk or aspects of it . For the most part, these measures tend to be study specific. None have been widely used, gained general acceptance, or established primacy in the field. In the present study we used the Health and Coastal Environment Questionnaire-V (HCEQ-V) , which wTen percent of the persons contacted for participation in the indirect impact group (Franklin County) declined participation for the following reasons: They were out of town (1%), busy managing oil spill–related problems during the period of our evaluations (4%), or worried that our research was funded by BP (5%). In the direct exposure group , approximately 12% of the people contacted declined participation. The reasons stated were involvement in oil spill cleanup operations (5%), managing other oil spill–related problems during the evaluation period (2%), or worried that participation would represent a violation of contractual confidentiality agreements with BP (5%).p = 0.09). We found no significant differences between the economic resource groups on any of the demographic or background measures. Base rates for lifetime history of treatment for depression, anxiety, or current alcohol problems were similar for all groups.We observed no statistically significant differences between the exposure groups with respect to simple attention (Digit Span), response inhibition (Stroop), clerical speed and accuracy , or divided attention and mental flexibility (Trails A and B) . The direct oil exposure group was slower on the pegboard task (psychomotor speed and accuracy) than the indirect exposure group, but the differences were not clinically significant. Cognitive scores were comparable between the income groups, and cognitive performance scores for all four groups were within the normal and expected ranges.n = 9) and those who were never diagnosed or treated for anxiety or depression (n = 85). When standard cutoffs suggesting clinical impairment were applied, we found indicators of clinically significant anxiety and depression across all study groups , the depression rates of both groups were higher than reported in 2008 in the region: 9.8% Florida and 13% Alabama .The number of persons with clinically significant depression was elevated in both income groups  relative to regional base rates , with siActive coping was used significantly more by the direct exposure group than by the indirectly impacted group . Particin = 9, mean resilience = 27) or without  a prior history of anxiety or depression (p = 0.10).We found no difference in the resilience scores between exposure groups. However, the income loss group had a significantly lower mean resilience score than the income stable group. Finally, when baseline history of anxiety or depression was considered across all groups, there was no statistically significant difference in resilience scores between participants with (p = 0.03).Results of the perceived risk survey  indicatep = 0.03). Finally, 22% of the direct exposure group considered BP to be a reliable source of information, compared with only 5% of the indirect exposure group (p = 0.01).When asked where they obtained their most reliable information about oil spill–related health matters, > 75% of all participants indicated newspapers or television . The department of health was viewed as a more reliable source of information by the indirectly impacted (25%) and income loss groups (32%) than by their comparison groups . Local fishermen were considered a reliable source of information by the persons who sustained income loss  and income loss with respect to acute psychological distress, coping, resilience, and perceived risk after the Deepwater Horizon oil spill disaster. As hypothesized, during the spill, people living in a Gulf Coast community with indirect impact had elevated levels of anxiety and depression similar to those of people living in communities where oil reached their shores. When participants were divided by spill-related income loss, the expected differences in psychological distress emerged. People who suffered income losses as a result of the spill reported significantly more tension/anxiety, depression, anger, fatigue, confusion, and overall mood disturbance than their income-stable counterparts. The income loss group also had a higher rate of clinically elevated depression scores than any other study group. In summary, these data highlight the potentially profound psychological impact the Deepwater Horizon disaster had on coastal communities with indirect impact, particularly if they sustained economic loss.Mechanisms of adjustment such as coping strategy and resilience are often viewed as buffers to the psychological impacts of stressful life events. In our study, the income loss group was more likely than the stable income group to use behavioral disengagement (giving up) as a coping strategy. Disengaging from coping efforts and other avoidant strategies has been associated previously with adverse psychological outcomes after disasters, including oil spills . The lowEconomic resource loss, socioeconomic adversity, and/or loss of job opportunities have been associated with course of depression, number of PTSD symptoms, or psychological distress after other disasters, including the Sierra Madre earthquake , Hurricane Hugo (South Carolina), and the 9/11 New York City terrorist attacks . Six yeaWith regard to perceived risk, both exposure groups and economic resource groups in the present study had similarly high levels of worry about the impact of the spill on the environment, human health, and seafood safety. Therefore, any direct relationship between environmental worry and acute psychological distress could not be examined. During the acute event, participants considered television and newspapers the most reliable source of human health information. People who sustained income loss were more likely to turn to the local fishermen and the department of health for their information. Meanwhile, BP was found to be a reliable source of information by the directly exposed community.The primary limitations of this study are sample size and sampling procedures, which may have led to sampling biases. The indirect impact group was larger, older, better educated, and included more women than the comparison group (which focused on persons working directly on the water). The collective and acute nature of disaster creates a unique challenge for community-based public health research. During this real-time assessment of psychological distress, our community partners, who were also community leaders, were deeply entrenched in other disaster- related matters. This precluded the implementation of labor-intensive, systematic sampling procedures. Within the context of this research model, we used the best available recruitment methods to assemble the participant samples. The absence of preexposure data and the cross-sectional approach represent additional limitations that preclude the ability to directly establish a causal relationship between the oil spill and distress of community members.Impacts of oil spills extend beyond communities where oil reaches the shoreline. This underscores the need to extend public health education and outreach, psychological monitoring, and mental health services beyond the direct spill areas. From a mental health perspective, people at risk of income loss comprise a particularly vulnerable population. Therefore, this group should be specifically targeted for financial counseling and support, alternative employment opportunities, and psychological interventions. These interventions need to be immediately available in the communities where the impacted individuals live.PTSD is the most often studied and most frequent and debilitating psychological disturbance that occurs after disasters . Longitu


To evaluate medical, economical and sociological variables underlying avoidable pediatric migration from Campania region.Analysis of years 2006–2010 hospital discharge records, extracted from the archive of Regional Health Agency (ArSan), classified by Major Diagnostic Categories, Aggregate Clinical Codes, Discipline of dismissal, Local Health Authorities of residence, and age group 0–14 years . Sociological variables were evaluated by questionnaires.A total of 68,316 hospital discharge records were released by extra-regional structures. Major diagnostic categories and Discipline of dismissal indicated that the most implicated diseases  were not always of very high complexity. The total cost paid by the Campania Region was 124.700.000 Euros. The need for more specialized hospital pediatric units and/or with more pediatric subspecialties in the native region was pointed out by most of the self-administered questionnaires.Pediatric migration is an important phenomenon with evident implications. The identification of the most concerned sub-specialties here reported can give useful information aiming to assist in the improvement of the existing pediatric resources in Campania region in the wider context of the national global child health advancement. Italian health system is based on regional economic resources, most of them being chronically deficient in Southern Italy. Each region has several Local Health Units (ASL), i.e. public authorities with legal personality, administrative, capital and management features, which provide health care organization in its own territory, and supply it through public or endorsed private structures. When a region is indebted, this determines a frequent reduction in adult and pediatric medical quality of care, even though the Italian health system aims to providing equality of the standards for all citizens .One of the natural consequences is patients’ cross-border mobility -5. This Studies in pediatric age are scarcely represented in international literature. The existing ones have shown that pediatric migration in search of better quality health care assistance is a relevant phenomenon particularly in Southern Italy regions, including Campania region . AlthougThe objective of our study is therefore to analyze with a multidisciplinary approach medical, sociological and economic conditions that underlie the phenomenon in the Campania Region, aiming to serve as a possible reference point for planning appropriate containment strategies valid for this, and possibly also for other indebted Italian regions with high pediatric migratory flows.The multidisciplinary research group consisted of the Chair of Pediatrics of the University of Salerno's School of Medicine and Surgery, the Departments of Sociology, and of Economics and Statistics of the University of Salerno, the “San Giovanni di Dio and Ruggi d’Aragona” Regional Teaching Hospital of Salerno, and ArSan  of Campania Region.Hospital admissions (years 2006–10) of patients aged 0–14 years -excluding those of healthy newborns- were analyzed through administrative hospital discharge records (SDO) available at the ArSan-Campania region database. SDO data were classified by MDC (Major Diagnostic Categories) that include 25 groups of organ diseases, ACC  that comprise the ICD-9-CM  codes into a set of 259 small classes of homogeneous diagnoses and 231 types of intervention, Discipline of dismissal, ASL of residence, and age group 0–14 years.The total adjusted cost was based on current rates (TUC) for hospital treatments.Focus groups with pediatricians of regional provinces consisted in an interactive discussion about pediatric migration, and were structured to know their point of views about pediatric health care in Campania region. Sociological variables were evaluated through a self-administered questionnaire  was 10.6%, with lesser values for the three Naples ASLs vs. the ASLs of the other four provinces .Comparison of our data with those of a previous preliminary study on the same phenomenon during the years 2002–2006  does not allow to find substantial differences in migratory flows, and confirms that the highest proportion of Campania children still migrates to Rome  Figure .Table As shown in Table Eighty-two questionnaires were administered to parents of children coming from South Italy and admitted to extra-regional hospitals. Patients were hospitalized mainly in units specializing in neurology, gastroenterology, nephrology, cardiology and hematology-oncology disorders. Extra-regional hospitalization in most cases (35%) had been recommended by the pediatricians of the same southern Italy hospitals in which some patients were initially admitted, and only in a minority of cases by their own trusted/primary care pediatrician (18%) or by friends and relatives (16%). The majority of migrating families (65%) had received a clinical report regarding their child by the medical staff of their Southern Italy hospitals. In most cases subsequent follow-up had already been planned in the same extra-regional structure (73%). During hospitalization most caregivers slept at shelters (38%), or at the hospital itself (31%), or at hotels (23%).Most questionnaires reported a real or perceived lack of specialized centers in Southern Italy as the major reason for extra-regional admittances (81.5%). Advanced technology, organization and expertise were the most important differences detected by the interviews Figure . The numResults of Campania region patients interviewed in Rome or Genoa and those of the set of questionnaires administered in Campania region by their primary care pediatricians did not show relevant differences as compared to those of the rest of Southern Italy patients.Pediatricians’ experience gathered in focus groups and pediatric resources survey results confirmed that mental disorders are those especially felt to need unavoidable extra-regional hospitalizations, corresponding to our results shown above.This study analyzes medical and socioeconomic variables of the phenomenon of pediatric health mobility in Campania region. However we believe that the study methodology of our research may be used also for other Italian regions with high rates of patients migration.In addition to causing stress to patients and their families, health migration determines significant costs to native region and subtracts economic resources to the development of their human and technological assets . In geneThe analysis of our results underlines that some pediatric sub-specialty areas such as pediatric neurology, endocrinology, gastroenterology, and rheumatology are major causes of extra-regional admissions despite the existence of a number of qualified/certified Referral Regional Centers for the same pathologies.A better insight into pediatric migratory flows brings to lights that more pronounced migratory flows of specific ASLs mirror the lack of local specialized spoke centers [e.g. hematology-oncology diseases in some provinces of Campania region (Avellino and Benevento) and for pediatric urology in Salerno’s province].Looking at our data and at regional resources survey, it emerges that a concrete reinforcement and/or rationalization of some existing pediatric resources  might contribute to reduce the proportion of avoidable migration. For others  it is possible that some existing excellences are not adequately publicized or efficiently interfaced with patients and/or their trusted pediatricians and peripheral general hospitals. A more complete survey of these and other pediatric resources is therefore needed since it might be useful to better acknowledge efficient units and define consequently the “avoidable” and “unavoidable” components of regional pediatric health mobility. In this regard one must consider the relevant role of family physicians in our country’s health care system: they not only act as a first point of consultation for patients, but also determines whether or not to refer them to subspecialty care or to other centers. It is possible that, at least for some cases, no sufficient communication between physicians at the Campania hospitals and primary care pediatricians still exists. It will therefore be worthwhile to check if extension -also to other provinces- of regional pediatric resources surveys as the one started by our University-Hospital-Pediatricians Network in Salerno, might have a positive effect on primary care pediatricians’ decision-making processes.It must also be verified whether 1. novel joint interregional ventures such as that for pediatric hematology-oncology between Regional Children’s Hospital Santobono-Pausilipon, Naples and Giannina Gaslini Institute, Genoa, 2. the recent experiences of delocalized general or specializing sections of Pediatric Hospital Bambino Gesù in Molise, Calabria, Basilicata, Sicily and Campania itself, and 3. the institution of the teaching hospital in the Salerno’s area, overall will contribute to cut costs for pediatric patients healthcare and to improve local care/cure qualities. Similarly, one must verify if the present tentative of unifying costly duplicate pediatric divisions existing in small hospitals that often insist on the same restricted geographical areas, may be the right cure for cutting costs. This might help in raising funds to obtain centralized adequate technological and staff updating at teaching hospital level.In any cases, a regional multidisciplinary observatory of pediatric migration finally might be useful to evaluate prospectively the effectiveness of adopted corrective measures.ACC: Aggregate Clinical Codes; ArSan: Regional Health Agency; ASL: Local Health Units; ICD-9-CM: International Classification of Diseases, Ninth Revision; MDC: Major Diagnostic Categories; SDO: Hospital discharge records; TUC: Current rates for hospital treatments.The authors declare that they have no competing interests.ad hoc pediatric meetings. All authors read and approved the final manuscript.PV supervised the study and the final MS draft; GP prepared bibliographical background, elaborated SDO data, and organized Focus groups and Questionnaires; EC and GL extracted and commented on SDO data from the regional archive of the ArSan; TS and GM participated in the sociological analysis; CP participated in the economical analysis; VS and AMB participated in the organization of This work was partially supported by University of Salerno FARB (ex MURST 60%) year 2011.Appendix 1. Multicenter epidemiological investigation on pediatric mobility -spring 2012.Click here for file