The substantial progresses in our understanding of biochemical-biological interplays that characterize many human diseases, coupled with extraordinary technical advances, are now generating important multidisciplinary convergences, leading the way to a new frontier, called integrated diagnostics. This new discipline, which is currently defined as convergence of imaging, pathology and laboratory tests with advanced information technology, has an enormous potential for revolutionizing diagnosis and therapeutic management of human diseases, including those causing the largest number of worldwide deaths . However, some important drawbacks should be overcome, mostly represented by insufficient information technology infrastructures, costs and enormous volume of different information that will be integrated and delivered. To overcome these hurdles, some specific strategies should be defined and implemented, such as planning major integration of exiting information systems or developing innovative ones, combining bioinformatics and imaging informatics, using health technology assessment for assessing cost and benefits, providing interpretative comments in integrated reports, developing and using expert systems and neural networks, overcoming cultural and political boundaries for generating multidisciplinary teams and integrated diagnostic algorithms.The current scenario of  According to the most recent statistics of the World Health Organization (WHO), the three worldwide leading causes of death are cardiovascular diseases , cancer  and infectious diseases   The global burden of cardiovascular disease is mostly sustained by ischemic heart disease , followed by stroke  and venous thromboembolism  (th percentile of the upper reference limit (URL)  is diagnosed in patients with clinical evidence of acute cardiac ischemia, with a rise and/or fall of cardiac troponin values and with at least one measurement exceeding the 99e.g. coronary revascularization), as well as stratification of short- and long-term risk of major adverse cardiovascular event (MACE), including reinfarction and death , prompt establishment of appropriate therapeutic measures   may be used for more clearly defining the aetiology of myocardial injury, thus providing an adjunctive and valuable contribution to laboratory testing and electrocardiography ), have a ~8-fold enhanced risk to die during a follow-up of 45 months compared to those with negative calcium score (odds ratio (OR), 8.43; 95% confidence interval (95%CI), 6.25 - 11.36; P < 0.001)  for quantifying coronary artery calcium score with high-sensitivity cardiac troponin enables to identify with 100% NPV a subset of patients at low risk of MACE , the diagnosis of acute ischemic stroke (AIS) is made with non-contrast computed tomography (NCCT), whilst the use of diffusion-weighted MRI (DW-MRI) remains questionable and currently limited to patients with negative NCCT findings  shall not be given to patients with AIS displaying platelet count < 100 x109/L, international normalized ratio (INR) > 1.7 and activated partial thromboplastin time (APTT) > 40 s  and pulmonary embolism (PE) (The generic definition of venous thromboembolism (VTE) encompasses the combination of two distinct but often associated clinical entities, e.g. older age, pregnancy) and pathological  conditions, which can only be identified or excluded with diagnostic imaging , and different imaging modalities , single photon emission computed tomography (SPECT)), which help constructing an ideal bridge between technologies used in laboratory medicine and radiology  fibrin-specific reporters permits to identify venous thrombi and dissect their vulnerability to fibrinolysis, thus amplifying the diagnostic accuracy and therapeutic effectiveness (The term “theranostics” (or “theragnostics”) is used to denote treatment strategies combining diagnostics with therapeutics (e.g. the discovery of genetic mutations and epigenetics determinants that drive cancer growth), coupled with notable technical advances, have considerably mutated the background and the role of pathologists in recent years, paving the way to development of relatively innovative diagnostics fields, namely molecular diagnostics and genomic profiling. Diagnostic imaging also plays an essential role in cancer care, since it participates to the initial diagnosis, and then contributes to surveillance, follow-up and therapeutic monitoring  will enable significant advances in diagnostic and prognostic accuracy , but can now be made also in blood and in other biological fluids, by means of a much less invasive venipuncture. The often misused or abused term “liquid biopsy” is precisely defined by the US National Cancer Institute (NCI) as “a test done on a sample of blood to look for cancer cells from a tumour that are circulating in the blood or for pieces of DNA from tumour cells that are in the blood”  , diagnosis , therapeutic monitoring , and establishing the prognosis  score, which includes platelet count in combination with creatinine and total bilirubin concentration) . Computed tomography scanning or MRI may also be used, since they are more sensitive than conventional radiographies for detecting a vast array of possible sources of infections in chest, abdomen and other bodily districts  have been obtained by implementing reinforcement learning for supporting sequential decision-making problem in patients with sepsis . NeIn the previous sections of this review, some paradigmatic examples have been discussed, corresponding to the three leading causes of worldwide deaths, to provide an overview on the current scenario and future perspectives of integrated diagnostics . CardiovThe IT infrastructure can perhaps be seen as one of the biggest drawbacks in integrated diagnostics. The current laboratory, radiology, pathology and even hospital information systems have been constructed and developed independently, so that their connectivity is poor and functional integration is challenging, time-consuming and expensive (per se encompasses a multi-professional and multidisciplinary assessment of cost-effectiveness of health technologies, based on active involvement of many different medical and diagnostic disciplines (Unfortunately, cost will be another major limiting step in development of integrated informatics platforms. Overcoming this hurdle will not be easy, since public funding in healthcare is substantially declining everywhere around the world, due to the residual effect of an unprecedented economic crisis (The possible convergence of laboratory, pathology and imaging test results within the same medical report then implies that an enormous volume of different information will challenge the mind of healthcare professionals, especially of those who are directly in charge of the patient and will need to take the most appropriate medical actions, unravelling many intricacies. Reinforcement of clinical decision support through expert interpretation and counselling will become unavoidable (A final important issue concerns the education needed for using integrated diagnostics. Laboratorians, pathologists and radiologists have faced and eagerly won many technical and practical challenges that have revolutionized their work during the past decades (In conclusion, integrated diagnostics can be considered one of the greatest opportunities for future healthcare, since it would permit to deliver more patient-centric care, obtain better outcomes and ultimately decrease cost over time. The chance to merge different diagnostic modalities within a single medical record will also boost the development of population-level databases, containing aggregated information on million of patients, and thus enabling to achieve a more holistic picture of many human diseases and developing more effective treatment. Additional efforts shall hence be made to foster the collaboration among different diagnostic disciplines, overcoming cultural, political and technical boundaries, for developing the diagnostic discipline of the future. Will integrated diagnostics contribute to put an end to laboratory medicine, at least as we now know it?


To the editor: I read with great interest the article by Ndeikoundam Ngangro et al. entitled ‘Bacterial sexually transmitted infections (STI) in France: recent trends and patients’ characteristics in 2016’, which showed an increased number of cases of syphilis, rectal lymphogranuloma venereum (LGV) and gonorrhoea in France between 2014 and 2016 [N.gonorrhoeae and XDR Mycoplasma genitalium, (iii) increase in the number of sexual partners per year among MSM, (iv) gastrointestinal (GI) and liver diseases related to the faecal-oral route of transmission particularly among MSM, (v) appearance of blood-borne diseases such as hepatitis C in the subgroup of highly sexually active MSM, (vi) discovery of possible sexual route of transmission for emerging infectious diseases , (vii) possibility for these latter diseases to be transmitted months after cure and (viii) history as story repeats itself [The reason why French public health specialists only recommend the test and treat approach for STI instead of prevention needs to be better explained; the continuous and marked surge of gonorrhoea and rectal LGV in men that have sex with men (MSM), for example, likely warrants more than a test and treat approach. There are at least eight reasons to worry about this continuous increase of STI: (i) re-occurrence of severe complications of gonorrhoea and syphilis with high rate of sequelae, (ii) worldwide increase of resistance to antibiotics including STI agents as recently illustrated with extensively drug-resistant (XDR) s itself .Is it possible that sexually transmitted disease history, including AIDS history, has been largely forgotten? From a historical perspective, AIDS epidemics in MSM were preceded by an increase in the number of sexual partners, STI diagnoses (such as gonorrhoea and syphilis) and outbreaks of faecal-orally transmitted GI and liver diseases . On anotWith a continuous increase in STI, it is surprising that condom use and safer sex is not more actively promoted by public health authorities . A majorIndeed, promoting the repeated use of antibiotics for treatment of recurrent STI and the use of PrEP for prophylaxis of HIV infection is questionable, as condoms are an effective and harmless prevention tool. Moreover, this contrasts with the current recommendations for controlled use of antimicrobial therapy to lower antimicrobial resistance .In conclusion, it should be highlighted that prevention of STI, through condom use and safer sex, is better, less harmful and cheaper than a cure . This is


American Indian and Alaska Native (AI/AN) communities are establishing new paths as more older adults develop Alzheimer’s and other dementias along with other co-morbidities. To offer a flexible framework of public health strategies that proactively address the growing issue of dementia among AI/ANs, Alzheimer’s Association and Centers for Disease Control and Prevention (CDC) developed the first-ever Healthy Brain Initiative Road Map for Indian Country. Partnering with International Association for Indigenous Aging supported Road Map development through virtual listening sessions and written comments from regional Native health experts, tribal aging service leaders, and tribal government officials. Many additional discussions, engagement of a cultural guide, and an additional partnership with National Indian Health Board further informed Road Map contents, graphic design, and marketing. Presenter will describe rationale for the process, themes from the consultations, and lessons learned by the Association and CDC that can apply to similar initiatives.


Integrated nutrition and agricultural interventions have the potential to improve the efficiency and effectiveness of investments in food security and nutrition. This article aimed to estimate the costs of an integrated agriculture and health intervention (Mama SASHA) focused on the promotion of orange-fleshed sweet potato (OFSP) production and consumption in Western Kenya. Programme activities included nutrition education and distribution of vouchers for OFSP vines during antenatal care and postnatal care (PNC) visits. We used expenditures and activity-based costing to estimate the financial costs during programme implementation (2011–13). Cost data were collected from monthly expense reports and interviews with staff members from all implementing organizations. Financial costs totalled US$507 809 for the project period. Recruiting and retaining women over the duration of their pregnancy and postpartum period required significant resources. Mama SASHA reached 3281 pregnant women at a cost of US$155 per beneficiary. Including both pregnant women and infants who attended PNC services with their mothers, the cost was US$110 per beneficiary. Joint planning, co-ordination and training across sectors drove 27% of programme costs. This study found that the average cost per beneficiary to implement an integrated agriculture, health and nutrition programme was substantial. Planning and implementing less intensive integrated interventions may be possible, and economies of scale may reduce overall costs. Empirical estimates of costs by components are critical for future planning and scaling up of integrated programmes. This is one of the few studies to address the challenge of capturing the costs of interventions that work across sectors to improve health and nutrition.The cost per beneficiary for the integrated agriculture-nutrition-health intervention was US$155, when considering women only, and reduced to US$110, when also including infants who attended postnatal care services. These costs are comparable with other community-based interventions.The costliest component of the intervention was integration, which included monthly feedback meetings and other co-ordination and monitoring activities by all partners and implementing agents (27%), followed by administration and overhead (23%) and training (15%).Scenarios for lowering costs through economies of scale and integration into routine services should be further explored. Agricultural and nutrition-sensitive interventions can complement health service and nutrition-specific interventions to improve child outcomes  antenatal care (ANC) services, with the aim of maximizing the benefits of orange-fleshed sweet potato (OFSP) on the health status of mothers and children <2 years of age. A comprehensive evaluation strategy assessed impact, acceptability, feasibility and affordability of the integrated approach  to estimate the total implementation costs and cost per beneficiary of the Mama SASHA intervention and (2) to identify potential efficiencies for scaling up the intervention to other locations where OFSP holds promise.The Sweetpotato Action for Security and Health in Africa (SASHA) was a 5-year multi-partner project designed to improve the food security and livelihoods of poor families in sub-Saharan Africa by exploiting the untapped potential of sweet potato.The Mama SASHA intervention was conducted through a combination of health facility and community-based strategies targeting pregnant women. After an initial pilot in 2009, the implementation start-up activities (planning and training) began in late 2010 and recurrent implementation activities ran from March 2011 to December 2013. See Mama SASHA implementing partners  received training to support the pregnant women with nutrition counselling, accessing vines and offering OFSP production support. Co-ordination and monitoring activities were critical for integrating the Mama SASHA project into existing ANC and postnatal care (PNC) services and for ensuring a shared understanding and coherent implementation of activities. Integration activities included annual, quarterly and monthly feedback meetings, transportation and per diems for all meeting participants, and NGO labour to support integration.This cost analysis estimated incremental total financial and unit costs for start-up and recurrent activities related to delivering the Mama SASHA activities, described above, at health facilities already supported by the USAID APHIAplus project. We used a mix of top-down expenditure analysis and bottom-up activity-based costing to understand resource use and financial costs. The analysis followed existing methodological guidance for primary health care costing in low- and middle-income countries , or the costs of community-based activities by established cadres of CHWs already supported by APHIA II and APHIAplus. For example, we included the costs associated with new NGO activities like managing the receipt and redemption of vouchers, supporting PWC, or initiating and supervising agricultural activities for establishing vine multiplication of new varieties of OFSP. The current analysis adopted a provider prospective, where the provider was a combination of the Kenyan government and NGO services based in Kenya.We also classified costs based on input categories for personnel, agriculture supplies, agriculture equipment, other consumable supplies, other capital equipment, transportation, travel per diem, allowances, mixed inputs, vouchers and other costs . We estiStart-up costs included costs on activities for planning, education and communication (IEC) materials development (December 2009 to December 2010), training programme development, establishing secondary VM plots, and promotion and awareness-raising activities (September 2010 to February 2011). Start-up costs were considered a type of fixed or capital cost, where we estimated their useful life years as 5 years (i.e. the life of the project). Recurrent costs were for inputs associated with maintaining the supply and demand for vines, supervision and support for health facilities, and integration activities, including any refresher training, occurring from March 2011 through December 2013.All research-related costs were excluded from this analysis. In addition to implementing the Mama SASHA project described here, some implementing organizations had additional research costs to support the overarching SASHA project research objectives. Personnel, transportation and travel costs were proportionately allocated to research based on staff time spent between research and implementation activities. Only personnel time spent on Mama SASHA implementation was included.We transcribed the international and local NGO project expense reports into an excel template. All data were entered by organization and assigned activity and input codes based on the cost categories described above and in The cost analysis uses two main summary measures of overall intervention service provision: (1) the number of beneficiaries reached and (2) the total points of contacts with beneficiaries. We estimated both using monthly data collected as part of routine Mama SASHA monitoring  the total number of single-count women who received and redeemed vouchers; and (2) 1+ the number of infants who attended a PNC visit with their mother.We aggregated incremental financial costs by year and by NGO organization for the implementation phase (2011–13). Unit costs were estimated as incremental financial costs per service delivery output described above , administration and overhead (23%) and training (15%). An additional one-fifth (22%) of the total costs were used to support agricultural activities related to establishing a continuous supply of vines (9%), ensuring adequate and continuous supply of roots to households (7%) and improving knowledge and practices of OFSP among beneficiaries and the community (6%), while a relatively smaller share of financial costs went to supporting health facilities in vine voucher programme distribution (5%). The remaining budget (9%) was allocated to planning, development of training and ICT materials, awareness-raising and sensitization, and depreciation of capital investments .Total recurrent costs and output declined over the 3-year period . The proTo our knowledge, this is the first study in sub-Saharan Africa to empirically estimate the costs of an integrated agriculture and health intervention implemented at both the community and facility levels. We estimated that the financial costs of reaching nearly 6000 beneficiaries (and over 18 000 contacts) in a 3-year period were just over US$500 000 or approximately US$170 000 per year, including start-up costs. When considering mother–baby pairs, the average unit costs were US$110 per beneficiary and US$28 per contact. Vine vouchers were the project’s critical integrating element: over 7000 pairs of vouchers were distributed to over 4600 women and infants. Each voucher and each mother receiving one or more vouchers were tracked from the health facility to the field. The financial value of the vouchers was low (US$1 per voucher pair redeemed), so the total reimbursement costs of vouchers comprised only a fraction of the overall project expenditure (1%). However, when considering more comprehensive costs of establishing a continuous supply of vines and the requisite health implementation activities for distributing and tracking the vouchers, the cost share of the voucher component was more substantial (around 20%).This study estimated intervention costs in several ways in order to understand each sector’s separate and joint financial contributions to an integrated agriculture and health intervention. Inter-sector co-ordination and feedback mechanisms supported demand generation and ensured a sustainable supply of vines but significantly increased the cost per beneficiary. Early operational research evaluating the pilot component  highlighPrevious studies have presented costs for nutrition interventions with similar complexities in linking health and community-based activities, such as treatment of severely malnourished children, and introducing OFSP through agriculture extension with enhanced nutrition education  shares several similarities with the Mama SASHA project, though CMAM does not include an agricultural component. In Bangladesh, Other household food-based strategies have varied implementation costs. Unpublished reports by Helen Keller International provided cost estimates for a 1996 pilot of homestead food production programme promoting household gardening of vitamin A-rich foods in Bangladesh at an adjusted cost of 2013 US$68 per household garden . More reSeveral study limitations are worth noting. First, this analysis presented information on financial costs and did not estimate the opportunity cost of time for health workers, agriculture extension agents, community volunteers and beneficiaries. However, key informant data presented in Second, in parsing out non-project-related expenses, we tried to make consistent decisions on what to include and exclude but were challenged by different financial accounting methods across the four implementing organizations. NGOs coded or categorized inputs or activities differently for many expenses related to workshops, training, personnel, travel, transportation and indirect/overhead expenses. In particular, we had to use our judgement to allocate vehicles and transportation costs to research and implementation activities, since we did not have detailed information on how vehicles and transport supported project activities. We may, therefore, have underestimated implementation costs. Alternatively, we may have overestimated costs as vehicle and transport costs sometimes served both purposes.Third, international NGOs incurred indirect costs related to fringe benefits and housing allowances for expatriate staff beyond the scope of the Mama SASHA project, so we estimated and included only the portion of those indirect costs that were directly related to the Mama SASHA project implementation. Further, we did not include labour and travel costs of international technical collaborators that contributed to the design of the proof-of-project concept and to annual work planning meetings, as the majority of these costs were for research design and management not directly related to intervention service delivery. Our results from the sensitivity analysis indicated that our cost estimates are fairly robust to changes in transportation, salaries of personnel and indirect expenses.Fourth, we did not include the costs of implementing and evaluating the 2010 pilot programme, though it was instrumental in refining the programme, helping implementation to run more smoothly, and achieving higher uptake. Including the pilot would increase the overall project costs, though it would also increase the total number of beneficiaries reached by 2453 pregnant and lactating women. Finally, our cost per beneficiary does not capture the total number of infants and family members who consumed OFSP as an indirect result of Mama SASHA. Doing so would yield lower unit costs.We estimated the Mama SASHA project to cost in the range of US$110 to $155 per direct beneficiary. Whether or not Mama SASHA is considered affordable will depend upon: the priorities of ministries of health and agriculture and international donors; sectoral organizations willingness to fund activities which cross sectors; the level of effort required to sustain or increase uptake over time; and the effects of moving to scale. At scale, we might observe economies of scope, as integrating activities allowed healthcare workers to more effectively reach their target population, leading to secondary cost savings  as well Future work might consider innovative ways to harness market forces and the private sector. In Western Kenya, there was a strong demand for OFSP vines by NGOs and community-based projects to improve agriculture, health and nutrition . As a result of Mama SASHA, a dozen VMs established sustainable businesses to produce and sell surplus vines to other local NGOs. Previous studies have demonstrated the importance of early OFSP adopters and vine producers that can effectively lower the costs of extension services to neighbouring communities and encourage more rapid diffusion (This study estimated the incremental costs of implementing an integrated nutrition and agricultural intervention in rural Kenya. Results suggest that the financial cost per beneficiary and the share of those costs needed for integrating activities across sectors can be substantial. Budgeting explicitly for joint training, regular monthly, quarterly and annual meetings will help future projects ensure that each sector has sufficient resources. Planning and implementing less intensive multi-sectoral interventions may be possible, and economies of scale may help to reduce overall costs. Empirical estimates of costs and their breakdown across sectors are critical to inform the design, planning and implementation of multi-sectoral programmes. Knowing costs by components enables thoughtful examination of where cost savings can be made with the goal of achieving the same level of impact.All research protocols were approved by the institutional review boards at PATH and the Kenya Medical Research Institute.czz083_Supplementary_AppendixClick here for additional data file.


Transforming our world: the 2030 agenda for sustainable development outlines a transformative vision with 17 sustainable development goals (SDGs) for economic, social and environmental development.Bulletin of the World Health Organization examines the relationship between health and the SDGs.Implementing the 2030 agenda requires a multistakeholder, multi-actor response. Innovations and development in policy, technology and research must include dialogue between governments, the private sector, civil society organizations and nongovernmental organizations; most importantly, strong community involvement is needed.More specifically, to reach target 3.8, to achieve universal health coverage, Member States must ensure access to health services by introducing protection against catastrophic health expenditure.,Universal health coverage could therefore contribute to achieving the SDGs by producing equitable and sustainable health outcomes. Many health disparities between people with different socioeconomic status are compounded by gaps in good governance. For instance, corruption makes access to health services, medication and information much more difficult for the vulnerable.,,Currently, robust data on health-related targets and indicators is lacking in many countries; developing better implementation and measurement tools, and linking data across sectors, is a cornerstone of the SDGs and should be a priority in global health policy dialogue.Preventing disease through healthy environments estimated that 23% of all deaths could be attributed to environmental issues such as air pollution, poor sanitation, exposure to radiation and other environment-related causes.The 2030 agenda also places emphasis on the environmental determinants of health. The 2016 World Health Organization report Thirteenth General Programme of Work 2019–2023,While countries present national voluntary annual reports at the high-level political forum held in New York, national and international development communities still lack efficient and effective data collection mechanisms, to better report on the status of the progress of Member States towards the SDGs. The WHO


In experimental neuroscientific research, anatomical location is a key attribute of experimental observations and critical for interpretation of results, replication of findings, and comparison of data across studies. With steadily rising numbers of publications reporting basic experimental results, there is an increasing need for integration and synthesis of data. Since comparison of data relies on consistently defined anatomical locations, it is a major concern that practices and precision in the reporting of location of observations from different types of experimental studies seem to vary considerably. To elucidate and possibly meet this challenge, we have evaluated and compared current practices for interpreting and documenting the anatomical location of measurements acquired from murine brains with different experimental methods. Our observations show substantial differences in approach, interpretation and reproducibility of anatomical locations among reports of different categories of experimental research, and strongly indicate that ambiguous reports of anatomical location can be attributed to missing descriptions. Based on these findings, we suggest a set of minimum requirements for documentation of anatomical location in experimental murine brain research. We furthermore demonstrate how these requirements have been applied in the EU Human Brain Project to optimize workflows for integration of heterogeneous data in common reference atlases. We propose broad adoption of some straightforward steps for improving the precision of location metadata and thereby facilitating interpretation, reuse and integration of data. Over last decades, considerable effort has been invested in large-scale the production of neuroscience data  brain atlases have been developed for murine brains  to serveTo first assess how anatomical location is reported in the neuroscience literature, we evaluated and compared current practices for interpreting and documenting the location of measurements in different disciplines of neuroscience that typically deal with invasive techniques or extraction of tissue. Our observations indicate substantial differences in approach, interpretation and reproducibility of anatomical location between different categories of experimental research, as well as a potential for improvement with relatively simple measures. Based on these observations, we have adjusted and optimized the Human Brain Project tools and workflows to accommodate the type of data and documentation typically used in different domains of experimental research on murine brains. We propose step-wise practical implementations that can improve current practices, and argue that these procedures increase reproducibility and facilitate integration of neuroscience data. We finally discuss costs and benefits of increasingly elaborate approaches.We performed a literature study to explore current practices for reporting anatomical information in different categories of experimental neuroscientific studies in murine brains.in situ hybridization (ISH); (2) axonal tract tracing; (3) transmission electron microscopy (TEM); (4) immunoblotting; (5) in vitro electrophysiology with slice preparations and microscopic visualization of recorded cells; (6) in vivo electrophysiology, and (7) two-photon and optogenetic imaging. Studies involving tomographic whole-brain imaging and trans-cranial measurements were not included.We focused on experimental studies involving invasive procedures or tissue extraction, and classified publications into the following seven methodological categories based on the principal methodology employed: (1) cytoarchitectonic staining techniques, including immunohistochemistry (IHC) and ∗ or neuroanatom∗ or neuro anatom∗ or neuron or neurons).mp.). Strings related to the specific methodologies of interest (see above) were added to this:Individual search strings were made for each methodological category, and a search was performed in Ovid MEDLINE. Except for the terms related to the specific methods, the criteria used for building the search strings were consistent across searches and contained the following: ((exp mice/or exp rats/) OR (mouse or mice or rat or rats).tw,kf.) AND ((brain or brains or neuroscien(1) OR ((in situ hybridization).tw,kf.)(2)∗.tw,kf.) for axonal tract tracing((retrograde or anterograde) adj trac(3)∗ or electron microscop∗)).tw,kf.) OR (transmission adj (electronmicroscop(4)∗ or immunoblot∗).tw,kf.)((western blot(5)∗ or electro physiolog∗ or cell recording)) or cell recording).tw,kf.)((((invitro or in vitro) adj2 (electrophysiolog(6)∗ or electro physiolog∗)).tw,kf((invivo or in vivo) adj2 (electrophysiolog(7)∗.tw,kf.)) OR ((((twophoton or two photon or two-photon or 2 photon or 2-photon) adj2 (microscop∗ or imaging)).tw,kf.)) were chosen from the selection of search entries by use of a random number generator and evaluated using the following inclusion criteria: (a) contained murine brain data; (b) presented original data; and (c) were published within the last 5 years. Papers not meeting these criteria were excluded and a new random paper selected.Papers  any additional information provided beyond the structure name ; (2) use of histological sections (without counterstaining); (3) use of (immuno-)histochemical staining to visualize anatomical features; (4) specification of spatial coordinates ; (5) documentation using images that show anatomical landmarks suitable for identifying location in addition to features of interest (see below); (6) annotation of anatomical landmarks or boundaries in images from the material; (7) images from multiple  sections through a region of interest; and (8) spatial registration of images to a reference atlas.and at least one other distinct anatomical landmark, such as a part of the ventricular system, a major white matter tract, or a distinct gray matter structure. Consequently, high-power images showing structural details of a smaller region, e.g., a part of the cerebral cortex with visible layers, were not considered sufficient to allow interpretation of anatomical location in this context.Some papers reported results obtained using several methodologies, but for each paper we only assessed the documentation related to the specific methodology for which the paper was selected. Documentation of anatomical location with images was only considered sufficient if images gave a reasonable overview of the regions of interest, allowing the reader to identify the position of the image relative to a reference atlas. We set the minimum standard to be that images should show the region of interest observation site in which some analysis had been performed . Alternatively, the region of interest may have been a site of an experimental procedure, or perturbation . In the case of multiple regions of interest of the same type, e.g., cell counting in several regions or multi-site electrode recordings, we assumed the same level of effort had been undertaken to determine the location of each site, and we evaluated the paper according to the best documented region. In the case of multiple regions of interest of different types, we evaluated both types of regions separately. In tract tracing studies, for example, there are sites of perturbation (injection of tracer) and observation (labeled features). For tracing studies we therefore assessed injection sites and terminal fields as individual reports of regions of interest. Thus, while 20 papers from each of the seven methodological categories were surveyed, the total number of papers used was 120, because each tract tracing paper was included in two of the categories . References to these 120 papers are given in Supplementary Table Most commonly, the region of interest was an We aimed to demonstrate how new tools and procedures can be applied in order to map and co-visualize data spanning several methodological categories, and to identify key strategies in this process that should influence how data are acquired and documented.1 or the Allen Mouse Common Coordinate Framework  together with the point coordinates extracted with LocaliZoom.We used the Human Brain Project software tool QuickNII  to regisin vivo electrophysiology; (2) transmission electron microscopy; (3) cytoarchitectonic staining techniques; and (4) in vitro electrophysiology with cell reconstruction. These categories represent four of the seven methodologies included in our literature survey, and the workflows used to map these data to anatomical space can easily be extended to the remaining categories.To demonstrate workflows for spatial integration of different types of data, we used existing or publicly available data sets from the following four methodological categories: (1) In vivo electrophysiology recording data from the rat hippocampal region were produced by Debora Ledergerber  were registered to the Waxholm Space atlas of the rat brain. Section material from the in vitro electrophysiology with cell reconstruction and in situ hybridization was mapped to the Allen Mouse Common Coordinate Framework of the mouse brain. Following spatial registration to atlas, images with associated atlas information were exported to LocaliZoom for visualization and retrieval of spatial coordinates.For each data set, section images were spatially registered to a reference atlas template using the QuickNII tool. The first three data sets  involving different types of experimental methods, and evaluated their inclusion of tissue sectioning and histological staining, specification of spatial coordinates, documentation with images (with or without annotations) and the use of spatial registration to anatomical reference atlases. We found systematic variations across methodological categories regarding the degree to which anatomical locations were described and documented  presented images of microscopic observations, only 60% provided images with visible anatomical landmarks  used spatial registration tools to map the position of their experimental images to anatomical reference atlases Employ and refer to a specific anatomical parcellation scheme(2)Provide precise semantic descriptions relating observations to anatomical landmarks or features(3)Define points or regions of interest using an anatomical illustration or diagram(4)Provide annotated images showing distinct anatomical landmarks(5)Report spatial coordinatesBelow, we specify and exemplify these recommendations in further detail.as it appears in the reference atlas, and (2) appropriate citation of the reference atlas (and version) employed. Reference to 3-D atlas templates, e.g., the Allen Mouse Common Coordinate Framework . Coordinates may indicate the level or distance of a section or slice from an anatomical landmark  or specific points defined by x, y, z coordinates. The method used to define coordinates should be specified and additional validation steps, such as e.g., histological confirmation of perioperative stereotaxic measurements supplemented with documentation using image(s) or illustrations, can improve precision.in vivo electrophysiology, immunohistochemistry, in situ hybridization, transmission electron microscopy and in vitro electrophysiology with cell reconstruction to a common spatial atlas framework. The core workflow, used to spatially combine features of interest from different types of data sets, involves three steps. We first link the data to the same anatomical reference framework, secondly extract spatial coordinates representing features of interest from each of the data sets and thirdly co-visualize the extracted features in a 3-D atlas viewer as a starting point for various analytic approaches. The workflow is implemented using a suite of digital atlas and viewer tools developed in the Human Brain Project. The QuickNII tool is developed for registering 2-D  images to a reference atlas by mapping a spatially corresponding, customized atlas image onto images  using the Neurolucida software tool , together with low-power images of sagittal sections images in which the labeled somata were visible. The sagittal section images were registered to the mouse brain atlas using QuickNII, following which the atlas coordinates corresponding to the center of the neuronal soma  document features of interest in relation to cellular or regional characteristics; (2) register images to a 3-D reference atlas framework; and, if possible (3) acquire multiple serial histological  images covering several anatomical landmarks.The anatomical boundaries of brain regions are usually defined by characteristic structural or functional features. These can be visualized by (immuno-)histological staining, such as the thionine or parvalbumin staining shown in Figure As shown in the examples provided in Figures Interpretation of anatomical location, particularly for the purpose of spatial registration, can be improved with use of serial section images that display multiple anatomical landmarks. Inclusion of more sections is particularly useful when determining deviations of section angles from the standard plane. The precision of such a registration can therefore be improved by including more section images than the ones used for analysis.Regardless of the atlas used and the methods for relating data to it, the anatomical information as extracted from the atlas  for the entire analyzed region(s) should be clearly communicated in publications and collections of metadata.We have here reviewed anatomical location metadata provided in recent neuroscience publications, and found considerable differences across subfields of neuroscience. We have proposed a set of method-independent, easily adopted practices (minimum requirements) that can significantly improve reproducibility of neuroanatomical locations reported in publications. Furthermore, we have shown that re-usability and integration of data can be improved with additional steps using new software tools and workflows developed through the Human Brain Project, and that these procedures are applicable to data obtained by a range of methods.Factors contributing to inconsistency and ambiguity in location metadata included (1) variable use of reference atlases, (2) lack of specification regarding nomenclatures, terms, and definitions used, (3) limited use of coordinate-based information, and (4) use of highly magnified image material without sufficient annotation as the only graphical display of data location. The amount of location metadata found in publications depended on the methodology with which the data had been obtained, likely pointing to different approaches and traditions having evolved as common practice within subfields of neuroscience.The minimum requirements presented here are intended to be flexible and easily applicable to any neuroscientific method. They essentially state that descriptions of locations should be complete, and precisely define the relationship of sites of interest to anatomical landmarks, by use of semantics, coordinates or graphical representations, and preferably a combination of these. Appropriate reference to a specific nomenclature and citation of the reference atlases consulted is an obvious requirement, which is easy to implement regardless of the method used, but as our results show, often overlooked. We claim that adherence to the minimum recommendations requires little additional effort by researchers, and can substantially improve the precision of anatomical descriptions and data interpretation in neuroscience publications. Our examples specify how this can be implemented for different types of data.However, comparison of descriptions based on text, reference atlases and image material remains dependent on substantial human interpretation. The second part of our work therefore demonstrate that data obtained by several methodologies, spanning spatial and temporal scales, may be thoroughly and accurately located in space using novel tools and workflows, and that the output of these procedures can be used to co-visualize data.in situ hybridization material, as well as in vivo electrophysiological recordings. In the case of electron microscopy data, the spatial correlation of features seen at the microscopic and ultrastructural levels is essential in order to map specific objects imaged at the electron microscopic level to a reference atlas. This was achieved here using low-power overview images acquired during tissue processing and images of semithin sections stained to show cytoarchitecture. Some steps could have been improved, e.g., by imaging the whole brain section before and after sectioning, and by keeping track of the location within the ultrathin section from which the electron microscopy images were obtained. An alternative approach would be to extract coordinates representing the perimeters of the data set, e.g., the corners of a block of tissue dissected from a vibratome section and prepared for electron microscopic imaging. Whether highly specific information about the position of individual cellular elements is desirable and attainable for a data set will depend on the research question and the methods of tissue preparation. Nevertheless, our example shows that even minor additions to common protocols  can give major improvements of precision of location metadata. For neuronal reconstruction data, we show that spatial coordinates recorded with a 3-D reconstruction software can be translated to atlas coordinates by using reference points visible in macroscopic section images. For mapping of more complex neuronal arbors in atlas space, annotation of at least four (and preferably more) reference points representing key landmarks in the neuronal reconstruction will increase precision. Again, access to low-power overview images documenting soma locatio relative to visible landmarks was critical for translating the location of reconstructed neurons to atlas space.The workflows tested here for mapping data to atlas space can be implemented for any neuroscience method, provided that image material showing features of interest in relation to anatomical landmarks is available. For methods where such features are readily seen in histological section images, the procedures are quite easily applicable, as seen in our examples using immunohistochemical and We lastly summarized the workflows developed through these examples as a set of improved practices, aimed to facilitate efforts to compare and integrate neuroscience data. Mapping data to a common anatomical framework is an effective means to allow comparison and facilitate integration of disparate data types, a key goal within the Human Brain Project . AdherenAdditional documentation and more extensive interpretation of anatomical locations, as exemplified above, requires additional efforts including production of additional material and documentation, as well as analytical efforts. Depending on the size of the data set, type and quality of images and the features to be extracted, the process of registering data, extracting and visualizing coordinates requires from a couple of days to a week. The workflows used to extract spatial coordinates for different data features in our examples, were based on manual annotations performed with the tool LocaliZoom. The advantage of this approach is that atlas coordinates are directly exported, but it can be tedious to apply to larger data sets. New tools and workflows are currently being developed in the Human Brain Project that will allow (semi-)automated extraction of labeled features from serial images .We argue that costs of such additional efforts are outweighed by improved precision of anatomical location metadata, and the added value gained by making data easier to compare across studies. Today, finding and comparing data in the literature based on a region of interest is a time-consuming task that often reveals inconsistencies in results. Indeed, flexible use of definitions has been related to poor reproducibility in science . Conceptwww.humanbrainproject.eu), requests for access to these tools can be directed to j.g.bjaalie@medisin.uio.no.The data sets generated for the literature survey of this study are available from the corresponding author upon request. The data sets used for testing procedures for spatial registration were obtained from public sources , or from generous colleagues as specified in the methods section. Requests to access these data sets can be directed to t.b.leergaard@medisin.uio.no. Software tools are available from the Human Brain Project (IB contributed to conceiving the study, performed analyses, contributed to development of workflows, and co-authored the manuscript. MØ and KA contributed to conceiving the study, performed analyses, and contributed to development of workflows. CB, HK, SY, and MP contributed to the analyses and development of workflows. JB supervised development of tools, infrastructure, and workflows and contributed to writing the paper. TL conceived and supervised the study, and co-authored the manuscript. All the authors reviewed and approved the manuscript.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Currently, various tools exist to evaluate knowledge and awareness of antibiotic use and antimicrobial resistance (AMR) and are applied by various organizations. Previous systematic reviews have focused mainly on study findings such as levels of knowledge and AMR awareness. However, the survey procedures and data instruments used ought to be scrutinized as well, since they are important contributors to credible results. This review aims to assess the study methods and procedures of existing population-based surveys and explore key components which determine the general population’s levels of knowledge and awareness of antibiotic use and AMR.We searched existing literature for population -based surveys which sought knowledge and awareness of antibiotic use or AMR in the general population. Databases searched included Ovid, MEDLINE and EMBASE, PsycINFO and Scopus, domestic journals and gray literature sources. Population-based cross-sectional studies published in English or Thai from January 2000 to December 2018 were included in the review. Quality assessment was conducted using the ‘Appraisal Tool for Cross-Sectional Studies’ (AXIS).All 22 studies included in the analysis had clear objectives focusing on assessing people’s levels of knowledge, awareness, attitudes and behavior relating to antibiotic use and awareness of AMR. These studies had employed appropriate methodologies for population-based cross-sectional surveys relative to research questions. More than half of studies (14 out of 22) had scientifically soundly designed methodologies which captured the representativeness of the population; whereas the remaining studies had unclear sample size estimations, inappropriate sample frames and selection biases. Half of the studies had tested the validity and reliability of the questionnaire. The common questions used by these surveys were categorized into four themes: behavior related to antibiotic use, knowledge and awareness of antibiotic use, knowledge and awareness of AMR and others such as receiving information about antibiotic use and AMR or cross-cutting issues like self-medication.This review identified four key features of good practices in antibiotic use and awareness surveys: a) clear survey objective; b) scientifically sound sampling techniques ensuring representativeness; c) strategies for recruitment of samples and survey administration methods; and d) credible measurement to prevent non-sampling biases. During questionnaire design, the health systems context in terms of access to health services and antibiotics should be taken into account. In conclusion, to maximize the use of surveys, the application of findings in surveys and associated factors related to antibiotic use and AMR should primarily generate public health interventions and target specific groups to make progress in solving AMR problems. Global efforts to assess public knowledge and awareness of antibiotic use and antimicrobial resistance (AMR) are underway. In 2015, the World Health Organization (WHO) developed a questionnaire survey to assess current public knowledge and awareness and behaviors related to antibiotic use in six WHO regions ,4. TheseIn recent years the quest to halt AMR has been materialized in many countries. Thailand is amongst the exemplary countries that made substantial effort to counter AMR. One of the five goals of Thailand’s National Strategic Plan on Antimicrobial Resistance (2017–2021) is to increase public knowledge and awareness of antibiotic use and AMR by 20% before 2021 . The ThaEmbedding an AMR module in national surveys has various advantages, such as the possibility for long-term monitoring and opportunities to assess factors associated with knowledge and awareness; it also saves costs compared with conducting independent surveys. Moreover, the merit of survey provides better understanding on behavioral pattern on antibiotic use (either misuse or overuse) in the population, which is one of the key contributing factors to the emergence of AMR. Survey information can serve as a basis to demonstrate an association between knowledge/awareness/practices on antibiotic use and AMR. Thus, it is necessary to establish suitable antibiotic use surveys with associated factors such as knowledge and awareness, in order to tackle with the rising of AMR trends.However, the national survey on AMR almost always face some difficulties and limitations such as difficulties in the analysis to claim causal relationships, the presence of limited number of independent parameters and information bias when respondents do not understand the questions. This module was adapted from international survey tools such as the Eurobarometer survey in 2009, 2013 and 2016  and the In attempts to fill existing knowledge gaps pertaining to survey instruments, this review aims to assess the procedures of population-based surveys that ensures representativeness and minimizes biases. It also explores common contents in the questions used by these population-based surveys and categorizes them into thematic areas. The review findings are useful for countries seeking to develop methods and tools to monitor population knowledge and awareness of antibiotic use and AMR in response to the Global Action Plan on AMR.This review was registered with PROSPERO database (CRD42019123385) to review protocol: search strategy, inclusion and exclusion criteria, quality assessment and data extraction.Search terms were developed along three domains: a) antibiotics or antimicrobial resistance; b) knowledge or awareness; and c) survey or questionnaire. Four international databases  were searched using the search terms as detailed in The inclusion criteria comprised publications on population-based cross-sectional surveys in the general population which had investigated either knowledge or awareness of antibiotic use or AMR. Publications in English or Thai from international and domestic peer reviewed journals, and gray literature sources which were published between January 2000 and December 2018 were included. Studies on specific population groups, clinical research or studies which could not be electronically retrieved were excluded from the review.Four researchers  were responsible for abstract screening and full paper review for eligibility. Two researchers screened titles and abstracts to see if they met eligible criteria. The abstracts were included by a consensus between the two researchers and a third opinion was sought if they disagreed. The same process was conducted for the full paper review to select the papers related to research question in term of household-based surveys.The quality of the eligible publications was assessed using the “Appraisal Tool for Cross-Sectional Studies (AXIS)”. AXIS is a descriptive quality assessment tool designed for critical assessment of cross-sectional surveys ,10. UsinData extraction was conducted into three sets: a) characteristics of studies: author, year of publication, objective, country, study design, sample size, eligible criteria, administration and tool development; b) themes emerging from common questions asked in the surveys to determine level of knowledge and awareness of antibiotic use and AMR or any relevant issues; and c) key findings in the studies.An electronic search comprising the four international databases and hand search of three domestic databases and international and domestic gray literature sources yielded a total of 2,761 records . After duplicate removal, there were 2,663 papers for abstract screening. 2,537 papers were excluded as they were not relevant leaving 120 records to be searched for full texts. Thirteen full papers that were not electronically available and thirteen duplicates were excluded. 94 full papers were reviewed for eligibility and 72 publications were excluded for not being relevant or pertinent to the review objectives. Finally, 22 studies met the eligible criteria and were included for analysis.A PRISMA flow describing the study recruitment process of this systematic review is shown in Almost all 19 studies) were published articles in peer-reviewed journals while 3 were reports 9 studies,11. Of 2The majority of the studies 20 studies) were conducted as single-country studies while 2 studies were multi-country studies at global and regional levels ,4. Among studies Regarding study design, 3 out of 22 studies were interventional studies which assessed the outcomes of campaign and educational interventions on the proper use of antibiotics ,17,28. TSample size varied depending on the sampling frame and approaches employed by each study. More than half of the studies ,24,27,29For sampling criteria, nearly half of studies (10 out of 22) recruited only adults over 15, 18 or 21 years old . Some stThe results of the quality assessment of 22 eligible studies by using the AXIS tool are shown in Tables Our analysis found that all publications had clear study objectives which focused on assessing the levels of knowledge and awareness or attitudes and behavior related to antibiotic use and AMR and associated factors.All studies employed the appropriate methodology of cross-sectional survey related to objectives. There were 14 studies ,24,28,29Half of the studies ,26,27,29Regarding the reporting of survey results, almost all studies presented adequate basic data and all results for the described methods, except three studies ,4,23 whiSeventeen studies discussed limitations including selection biases ,25,26,28Regarding conflict of interests and ethical reviews, five studies did not clearly declare funding sources which might influence authors’ interpretation of the results ,12,23,27According to AXIS quality assessment, the tool does not provide a numeric scale for assessment, but it is flexible enough for users to judge the quality of the paper overall. However, authors in this systematic review classified all papers into three types based on methodology, results and discussions: 1) fully qualified; 2) partly qualified; and 3) unqualified. Fully qualified means the studies are qualified in all parts; there are no studies which reach this qualification. Partly qualified considers the studies that have qualifications in some parts; there are six studies in this group ,18,21,27Of the 22 studies, 13 ,27,28,29Four themes emerged from the analysis of the contents of the questionnaire: a) behavior related to antibiotic use; b) knowledge and awareness of antibiotic use; c) knowledge and awareness of AMR and d) other issues such as receiving information and advice about proper use of antibiotics, or AMR campaign message and cross-cutting issues such as self-medication. See With regard to behavior-related antibiotic use, we identified four sub-themes covering: 1) frequency of using antibiotics in the recall period such as one month, six months or a year; 2) source of antibiotics; 3) clinical indications or conditions for which antibiotics are used; and 4) instruction and advice from drug sellers or pharmacists on the proper use of antibiotics.For knowledge and awareness of antibiotic use, three sub-themes emerged: 1) antibiotic names; 2) general knowledge; and 3) awareness of using antibiotics in common cold and flu symptoms. Questions were asked about respondents’ recognition of antibiotics, for example whether penicillin or tetracycline were antibiotics or not. In terms of general knowledge, questions were asked about the mechanism of action of antibiotics, such as its action towards bacteria or viruses, its side-effects and allergies, and inappropriate antibiotic use. Finally, concerning awareness of antibiotic use, questions were designed to explore opinions about antibiotic use for common cold and flu symptoms.On knowledge and awareness of AMR, various questions in the survey tools were categorized into three subthemes: 1) definition of AMR; 2) general knowledge about AMR; and 3) awareness of AMR. The general knowledge questions focused on misuse, overuse, sub-optimal use and inappropriate use of antibiotics, which could lead to AMR and the spread of resistant bacteria. Concerning awareness of AMR, various questions explored people’s concerns about AMR, which had the potential to affect themselves, their families and countries.Self-medication with antibiotics is a cross-cutting issue in all the three thematic areas. Questions explored the necessity of completing the full course of antibiotics and proper management of the leftover antibiotics.Additional questions explored exposure to public information relating to proper use of antibiotics and AMR. These included media channels and sources of information such as health professionals, and the impact of this information on people’s behavior in relation to antibiotic use. For doctor-patient relationships, the questions related to trust and communication between people and healthcare providers.The systematic review observed several important features in design and methodology of included studies that would be useful for developing a tool to determine levels of knowledge and awareness of antibiotic use and AMR.Setting objectives is vital to guide study design and all included studies had clear objectives focusing on assessing levels of knowledge, awareness or attitudes and behavior related to antibiotic use and awareness of AMR and associated factors. A cross-sectional survey is appropriate for the assessment of population knowledge about and awareness of proper use of antibiotics under the resource constraints. It measures exposure and outcomes at the same time and can find possible associations between exposure and outcomes . Cross-sAlthough various methods can be used for sampling and recruitment, the key strengths of household-based cross-sectional surveys is the representativeness of the population. Although the sizes of samples are usually limited by the budget available for very large surveys, a representative sampling frame is essential for generalization of the survey findings to the population . InapproWe acknowledge that while random sampling is ideal as it properly represents the population, it is time- and resource-consuming. Stratified random sampling and cluster random sampling can be applied to household-surveys as these methods can also achieve representativeness and reduce selection bias. Cluster random sampling is also less costly and feasible; it is a common method used by many studies .Recruiting samples such as adult members or those who have clear understanding of the language used in surveys is critical for ensuring high-quality responses in many surveys. However, specific sampling methods may introduce selection biases, which should be considered before setting inclusion and exclusion criteria.The high level of non-response rate such as refusals, unreachable households or incomplete data compromises the validity of survey results and conclusions .Although two studies had low response rates, only Vallin M. et al (2016) mentioned this consideration in the discussion section. Various measures can be applied to minimize non-response errors such as making appointments for follow-up interviews for those who were absent on the interview days or using combined user-friendly survey instruments such as face-to-face interviews, telephone, mail or online self-administered surveys . Even whTwo broad methods of questionnaire administration are identified in this review: a) interview survey, either face-to-face or the use of telephone by trained interviewers; and b) self-administration either through postal or internet methods. Using multiple survey methods, when no single method is adequate to address research objective, can minimize the low response rate, prevent coverage, measurement and non-response errors . Each meMany studies addressed limitations about coverage errors and measurement errors.In term of coverage errors, Andre´ M. et al (2010) addressed the fact that 6% of the Swedish population aged 16–75 years did not have a fixed telephone line in 2006. Parimi N. et al (2002) also mentioned that 10% of the households in Trinidad and Tobago did not have telephone service and that 15% of the Telecommunication Services customers have unlisted telephone numbers. However, the limitations of questionnaire administration depend on the context specific to each country.In relation to measurement errors, Parimi N. et al (2002), Eng JV. et al. (2003) and Barah F. and Goncalves V. (2010) raised concerns about the level of understanding as regard to the questionnaire such as the term ‘antibiotics’ or explanation about illness and treatments. Therefore, some studies reduced these errors by setting criteria to recruit respondents who understood the term ‘antibiotics’ or to those who had used it before. Nevertheless, selection bias should be taken into consideration when studies select based on these specific groups. Interestingly, findings from Widayati A. et al (2012) showed that the characteristics data from groups of responders who were and were not familiar with antibiotics, were not significantly different. It means using this inclusion criterion was useful for ensuring the validity of the questionnaire.Tailor-made design in line with country contexts is important. For example, in countries with a high prevalence of “polypharmacy” which means using multiple drugs to treat a single ailment or condition at the same time, a careful design is needed to ensure correct interpretation of respondents’ understanding and their ability to distinguish antibiotics from vitamins and analgesic they use. Antibiotics are one of the most common items in polypharmacy, which can cause serious adverse drug events or drug interactions . AdditioWith regard to the validity and reliability of measurement, half of these 22 studies did not report testing validity and reliability before finalizing the questionnaire. Although some questionnaires were developed by other studies, the validity and reliability test are still essential because of the difference in population, health systems, culture and terminology for which adaptation to local contexts would be required.Key findings from these studies showed the differences in prevalence regarding antibiotic use, levels of knowledge of antibiotics and awareness of AMR, frequency and sources of receiving information about antibiotic and its use and AMR. However, there is no study expounding on the outcomes of surveys, including further implications such as impacts on AMR trends. All studies tried to identify the gaps in low levels of knowledge and awareness in terms of contents and characteristics of population in these groups. Furthermore, almost all studies assessed the association between demographics, for example, sex, age, education levels, wealth status with levels of knowledge and awareness, practices, regarding to antibiotic use and AMR except Ahmad H. et al 2013). According to findings, education levels were proven as consensual factors associated with knowledge and awareness while other factors differed depended on each study. Some studies found the significant association between key variables such as exposure to information or campaigns with levels of knowledge and awareness , and lev. AccordiAligned with global action plan on AMR, surveillance on levels of knowledge and awareness can contribute to the design of interventions which can change the population’s behavior on antibiotic use which could potentially lead to a reduction in AMR . NonetheTo change pattern of inappropriate uses in the population, it is necessary to have strategies or policies developed based on survey evidences. Experts and academics in the field should discuss and reach consensus on the required questions in the AMR survey module. The critical point is the linkage between levels of knowledge and awareness to behaviors which are influenced by various factors such as access to healthcare or social and cultural aspects . The surThe strength of this study is the focus on evaluation of questionnaire tools in household-based cross-sectional surveys. The systematic review contributes to new knowledge about the monitoring of knowledge and awareness of antibiotic use and AMR in two key areas. Firstly, it provides quality assessment of these cross-sectional surveys, which is important for tool development and data collection. We find that AXIS is a useful tool which provides qualitative assessment for the review of survey methodologies ,10. SecoHowever, there remain some limitations. For instance, firstly, despite the authors widened the search strategy as large as possible; it is very likely that some studies had been left out, particularly the gray literature in the archives of domestic universities or research institutes. Secondly, this review was unable to capture the linkage between AMR tools and the actual knowledge and behavior of antibiotic use in the wider population. This issue cannot be addressed by the review; primary data collection through either quantitative survey or qualitative interview is needed. In addition, a more complex review design   are likeIn response to AMR threats, countries need to assess their population’s knowledge and awareness of antibiotic use and AMR. Valid household-based assessments require clear survey objectives, valid and reliable tools for measurement, representativeness for generalizing the survey findings to the population and minimize sampling and non-sampling biases.The survey design needs to take into account local contexts and terminologies related to medicines, antibiotics and disease conditions used by the communities, and recruit qualified respondents who can provide accurate responses representing the population. Common questions in existing household-based surveys cover four thematic areas: behavior related to antibiotic use, knowledge and awareness of antibiotic use, knowledge and awareness of AMR and others such as receiving information about antibiotic use and AMR or cross-cutting issues like self-medication.Countries can learn from previous survey instruments applied by other and avoid mistakes. Accurate survey tools contribute to valid evidence which can be used to inform policies for specific interventions to improve population knowledge and awareness on antibiotics and AMR. The country-specific health system context of access to health services and antibiotics should be taken into account in the design of the survey questionnaire. Identifying levels of knowledge and awareness of antibiotic use and AMR is crucial. Eventually the utmost goals of such surveys would be to enhance the application of this knowledge to target specific target groups as well as to generate public health interventions related to antibiotic use and mitigating AMR.


Background: Although late-life suicide in rural China is a matter of concern, research is scarce addressing the association between capability of daily living activities, family function, and late-life suicide. We conducted this psychological autopsy study to explore associations between disability in daily living activities, family dysfunction, and late-life suicide in rural China.Methods: Using a 1:1 matched case–control design, we collected data from 242 elderly suicide cases and 242 living community controls in rural China using the psychological autopsy method. We used Structured Clinical Interview for the Diagnostic and Statistical Manual of Mental Disorders (SCID), Activities of Daily Living Scale (ADL), and Family Adaptive, Partnership, Growth, Affection and Resolve scale (APGAR) to assess the presence of mental disorders, capability of daily living activities, and family function, respectively.Results: Compared with the living controls, suicide cases presented more severe impairment in capability of daily living activities and poorer family function. After controlling for all other factors, capability of daily living activities and family function remained in the final model. The results of the multivariate analysis also show that the presence of a mental disorder, lower levels of social support, and increased number of life events in the last year were significantly associated with elevated suicide risk.Conclusions: Disability in daily living activities and family dysfunction are associated with elevated risk of late-life suicide in rural China. It is warranted to design programs, including family interventions, peer-support groups, and community programs, to help the rural elderly improve activities of daily living and obtain the social support they need to prevent suicidal behaviors. Late-life suicide in rural China is a matter of concern . The suiWith aging, capability of daily living activities will decline. Studies have shown that disability in activities of daily living is related to current suicidal ideation and past suicide attempts in elderly people , 5. PsycIn most cases, elderly disabled people in rural China are taken care of by a spouse or an adult child at home . This hiUsing a 1:1 matched case–control design, this psychological autopsy study aims to investigate capability of daily living activities and family function preceding death among elderly suicide cases and to explore associations between disability in daily living activities, family dysfunction, and late-life suicide in rural China.In this study, 242 elderly suicides (aged 60 years and over) were identified from 12 counties of Shandong Province, Hunan Province, and Guangxi Province from June 2014 to September 2015. For each suicide case, one living control person with the same gender and birth year (±3 years) was randomly chosen from the same village for each suicide case. Two independent interviews with the next of kin and other individuals who were familiar with the subjects were conducted. Data from these interviews were aggregated for analysis following these principles: a) For demographic information, we basically relied on answers by the next of kin of the subjects, and b) for other risk factors, we recorded a symptom/problem as present if it was endorsed by either informant. The details of the subjects’ selection and interview procedures have been described in previous publications .The institutional review boards of Shandong University, Central South University, and Guangxi Medical University approved this psychological autopsy study. Written informed consent for the publication of data and any accompanying data were obtained from the next of kin of each suicide case and the living control.Socio-demographic characteristics including gender, age, educational background, marital status, employment status, family annual income, living arrangement, and serious/chronic physical illness were collected. People that were married and living with the spouse or cohabiting were classified as “currently married,” while people with other marital status  were classified as “non-currently married.”The Chinese version of the Structured Clinical Interview for the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition  was used to generate current diagnoses of mental disorder . Diagnosvia the Activities of Daily Living (ADL) Scale (able to perform an activity independently) to 4 (unable to perform an activity by oneself). The total score ranges from 14 to 56, with higher scores indicating worse functioning of daily living activities. Elderly people were classified into three categories based on the total ADL scores: normal (≤15), mildly impaired (Capability of daily living activities was measured L) Scale . It consimpaired –22, and impaired .seldom) to 2 (often). The total score ranges from 0 to 10, with higher scores indicating higher levels of family function. Elderly people were classified into three categories based on the total APGAR scores: low (≤3), moderate  scale . This ismoderate –6, and gSocial support was measured by the 23-item Duke Social Support Index (DSSI) . It consStressful life events in the last 12 months before death or investigation were measured by the Life Events Scale for the Elderly (LESE), which was developed specifically for older adults in China and consist of 46 items covering health, family, and social related life events .We combined the information provided by the two informants as the proxy data for each suicide case and living control. Regarding socio-demographic data, we relied on the information provided by the first informant. For psychosocial factors , we chose the positive values from the two informant to integrate proxy data, taking into consideration any targeting symptoms or behaviors if observed by either informant.Odds ratios (ORs) for committing suicide were calculated using conditional logistic regression. All factors were included in the multivariate analysis (enter). All analyses were performed with SPSS version 23.0 . The significance levels of this study were set at 0.05.Background characteristics are summarized in Univariate analyses showed that the suicide cases were more likely to be non-currently married, live alone, and have mental disorders and physical illnesses, severely impaired capability of daily living activities, poorer family function, and lower levels of social support than the living controls. The life events with significantly increased ORs for suicide are also reported in In addition, capability of daily living activities and family function remained in the final multivariate model. The results of the multivariate analyses also show that the presence of mental disorders, lower levels of social support, and an increased number of life events in the last year were significantly associated with elevated suicide risk  improve their activities of daily living and obtain the social support they need to prevent suicidal behaviors.The raw data supporting the conclusions of this manuscript will be made available by the authors, without undue reservation, to any qualified researcher.The studies involving human participants were reviewed and approved by Central South University. The patients/participants provided their written informed consent to participate in this study.RC conducted the data analysis and drafted the manuscript. CJ, ZM, LN, and LZ contributed to the study design and provided substantial editorial input in the drafting of the manuscript. All authors read and approved the final manuscript.This work was supported by the American Foundation of Suicide Prevention to LZ (grant no. SRG-0-169-12).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.


Routine immunization programs face many challenges in settings such as Papua New Guinea with dispersed rural populations, rugged geography and limited resources for transport and health. Low routine coverage contributes to disease outbreaks such as measles and the polio that re-appeared in 2018. We report on an in-depth local assessment that aimed to document immunization service provision so as to review a new national strategy, and consider how routine immunization could be better strengthened.In East New Britain Province, over 2016 and 17, we carried out a cross-sectional assessment of 12 rural health facilities, staff and clients. The study was timed to follow implementation of a new national strategy for strengthening routine immunization. We used interview, structured observation, and records review, informed by theory-based evaluation, a World Health Organization quality checklist, and other health services research tools.We documented strengths and weaknesses across six categories of program performance relevant to national immunization strategy and global standards. We found an immunization service with an operational level of staff, equipment and procedures in place; but one that could reach only half to two thirds of its target population. Stronger routine services require improvement in: understanding of population catchments, tracking the unvaccinated, reach and efficiency of outreach visits, staff knowledge of vaccination at birth and beyond the first year of life, handling of multi-dose vials, and engagement of community members. Many local suggestions to enhance national plans, included more reliable on-demand services, integration of other family health services and increased involvement of men.The national strategy addresses most local gaps, but implementation and resourcing requires greater commitment. Long-term strengthening requires a major increase in centrally-allocated resources, however there are immediate locally feasible steps within current resources that could boost coverage and quality of routine immunization especially through better population-based local planning, and stronger community engagement. Our results also suggest areas where vaccination campaigns in PNG can contribute to routine immunization services. Stronger routine immunization programs are critical to the ambitious Global Vaccine Action Plan 2011–2020), however immunization coverage is not increasing as planned in many difficult settings challenged by expanding childhood cohorts, population displacement by conflict or natural disasters, and limited resources to overcome geographical and infrastructural challenges 1–2020, h, contrasMeasles, having been suppressed by regular supplementary immunization activities (SIAs) for 8 years, returned to PNG in a major outbreak in 2014, and polio, after a 20 year hiatus, returned in 2018 , 6. In tThis paper reports on a cross-sectional health services assessment investigating PNG government efforts to improve routine immunization prior to the polio outbreak. PNG had in 2015 introduced a new strategy to improve routine immunization and reduce reliance on SIAs, termed the Special Integrated Routine EPI Strengthening Program (SIREP) , 10. ThiOur study focused on modifiable aspects of front-line services recognizing that, for coverage to increase, strategies to strengthen health system elements must ultimately enable changes in service delivery and uptake. Study objectives were to measure current infrastructure, equipment and supplies for preventive care in infancy; assess what health workers know, think and do in relation to providing postnatal and infancy services; assess health workers’ responses to new strategies; and identify opportunities for health system strengthening and improved quality of care. We devised an evaluation framework that explicitly tested important elements of the SIREP strategy (noted in the Introduction), and that also referenced WHO standards for routine immunization programs , 15.Our study setting was East New Britain province (ENBP), part of a large island in PNG’s north-east, whose population   live in We carried out a cross-sectional assessment of health facilities, staff and clients from November 2016 to January 2017, timed to follow the initial rounds of SIREP training and implementation. Sites surveyed comprised 12 clinics providing immunization services, nine in fixed facilities and three community outreach sites; purposefully chosen as they are all linked to the health institutions providing approximately 80% of maternal and child health care in ENBP [Table Data collection was carried out by trained local research officers using electronic tablets supplemented by paper-based note-taking. The research team included policy-makers and managers at national and provincial levels; however these investigators were excluded from front-line data collection or initial analyses, to avoid bias. Research officers were trained in quantitative and qualitative data collection, including techniques to minimise social acceptability bias, and to assess and counter perceived power imbalance between themselves and interview subjects. All free-text interview responses were recorded verbatim, focus group discussions were documented by a dedicated note taker, and both were digitally recorded for cross-checking. Interviews were conducted in English and focus group discussions in Tok Pisin; both official languages of PNG.Quantitative measures from audit, structured observation and interview elements (such as for knowledge) were reported as proportions with no further statistical manipulation, respecting the purposeful sampling in our design. Thematic analysis of qualitative data was carried out by the first author (after translation of focus group discussion data), then validated by three other investigators (including two Tok Pisin speakers). After coding for themes predetermined in our conceptual framework and design, data were re-examined for emergent themes. In 2017, for critique and validation, a detailed data report was provided to all investigators and a summary provided to national and provincial stakeholders; this also allowed early dissemination of policy implications. Additional file Key findings from all data sources are summarised under six categories Table  from ourFindings demonstrated that services were largely provided as planned from static clinics and some outreach sites Table . SeveralInterviews Table  demonstrMost staff at interview reported integration of other services with immunization Table  as imporAs listed in Table All participants (staff in interviews and community members in discussions), when prompted were able to describe local strengths or suggest improvements. Common ideas proposed by staff included more personnel, stronger support for transport needed to do outreach, better community engagement, more active community education, involvement of male parents or care-givers, and offering desirable extra services for both mother and baby. When asked to rank priorities, staff rated reliable vaccine supply and renewal of equipment and infrastructure as more important than staff numbers or staff knowledge. Care-givers sought more frequent, reliable and ‘on-demand’ services, especially outreach, noting travel time and costs as a common barrier to uptake. Mothers, more often than staff, asked for the addition of family planning, promotion of reproductive health, and maternal illness care at immunization clinics.Our findings depict an immunization service with an operational level of staff, equipment and procedures in place; but one that reaches just half to two thirds of its target population. The service strengths are similar to, or better than, many other sites in PNG , and theWithin current resources, improvements in coverage should be achievable with a fuller implementation of the changes to local service planning envisaged in the SIREP strategy. This recognises that many clinics see few clients (25% with 3 or less), and the fact that most planning is not yet tuned to where most children live. Other persisting gaps in knowledge and capacity that were prime targets of the SIREP strategy include improving catchment population data, increased frequency of service availability, a greater number of outreach points, and quarterly intensification of outreach. Change through improved local planning to reinvigorate outreach has proven successful in settings in Africa and Asia  that shaOur findings also indicate opportunities for increased community engagement and mobilisation; through increased group and individual counselling in the vaccination encounter and the creation and provision attractive, durable, “take-home” information products, aiming to build community demand for a timely, complete schedule of vaccination. Outreach can benefit from stronger, formalised involvement of local leadership, possibly with the deployment of trained lay health workers; such community resources can also help register and track children needing vaccination. Improved session practices, including ensuring managerial and stock support to enable staff to open multi-dose vials even for one child; and the institution of AEFI equipment and periods of observation . This mix of enhanced community engagement plus improved local planning has driven routine immunization improvements in difficult settings in sub-Saharan Africa , 21, andPNG’s 2018 polio outbreak has necessitated a major emergency response, with national and sub-national campaigns initially for polio vaccination alone and later with other antigens, particularly measles-rubella, similar to previous SIAs in that country , 23. In There is global evidence, especially for measles/rubella SIAs, that they can boost routine programs ; but onlIt is clear that changes limited to the front-line are insufficient and central reforms of management, a country-led technical advisory group, procurement and financing, and national re-equipping are also needed and have been repeatedly advised , 11, 27;One aspiration of the SIREP strategy, and of global immunization programs , is the Our sample was restricted to functioning services and families who were willing and able to use those services so our study primarily relates to improving outcomes within existing services. Our data collection took place over the fourth and first quarters of the year, when wet weather events could bias perceptions of access. Despite careful training in unobtrusive observation and non-leading interviewing, there may be some observer effect and/or social acceptability bias affecting the validity of our findings. Single author coding of themes in qualitative analysis increases the risk of bias; our mitigation was to critically reflect on research perspective and carefully cross-check all inferences with local research staff, implementers and policy-makers. Study strengths include the assessment of a representative sample of functioning services, as well as the use of a broad mix of methods and attempt at more detailed interviewing than is the norm in previous service evaluations.) for routine program strengthening. Our results call for increased resourcing of and commitment to this approach, and also suggest areas where vaccination campaigns in PNG can contribute to routine immunization services.Our assessment of front-line immunization services in rural PNG found opportunities to boost coverage and quality, even within current resources, especially through better population-based local planning, and stronger community engagement. Many, but not all, were contained in PNG’s recent national strategy (SIREPAdditional file 1. Additional quantitative knowledge data and thematic coding of qualitative data.