The benefits of eHealth  have previously been documented in the literature. Health care providers  are the key driving force in pushing eHealth initiatives. Without their acceptance and actual use, those eHealth benefits would be unlikely to be reaped.To identify and synthesize influential factors to health care providers’ acceptance of various eHealth systems.This systematic literature review was conducted in four steps. The first two steps facilitated the location and identification of relevant articles. The third step extracted key information from those articles including the studies’ characteristics and results. In the last step, identified factors were analyzed and grouped in accordance with the Unified Theory of Acceptance and Use of Technology (UTAUT).This study included 93 papers that have studied health care providers’ acceptance of eHealth. From these papers, 40 factors were identified and grouped into 7 clusters: (1) health care provider characteristics, (2) medical practice characteristics, (3) voluntariness of use, (4) performance expectancy, (5) effort expectancy, (6) social influence, and (7) facilitating or inhibiting conditions.The grouping results demonstrated that the UTAUT model is useful for organizing the literature but has its limitations. Due to the complex contextual dynamics of health care settings, our work suggested that there would be potential to extend theories on information technology adoption, which is of great benefit to readers interested in learning more on the topic. Practically, these findings may help health care decision makers proactively introduce interventions to encourage acceptance of eHealth and may also assist health policy makers refine relevant policies to promote the eHealth innovation. Poor health care outcomes lead to increased levels of morbidity and mortality, and obstruct countries’ prosperity and business profitability eg, ,2). eHea. eHea2])eHealth is an emerging field at the intersection of medical informatics, public health, and business, and refers to health services and information delivered or enhanced through the Internet and other related technologies ,8. DiffeWhile there has been high interest in eHealth, the adoption and acceptance rates have not been high enough for health care systems to experience the maximal benefits eHealth has to offer . Past exA broad spectrum of research methodologies have been used to study eHealth adoption and acceptance factors based on information provided in published studies . The metHealth care providers are the key driving force in pushing eHealth initiatives . eHealthIn light of the guidelines originally proposed by ,18 and aA literature search was conducted between October and November 2011 using 8 online databases: Medline, Cinahl, Web of Science, PubMed, PsychInfo, ERIC, ProQuest Science Journals, and EMBASE. These databases were thought to be the most likely to publish eHealth adoption related work . While the government in some cases funds the start-up cost of an eHealth project , health care providers may still need to undertake the operation and enhancement cost of their system . In smalAnother important issue is interoperability. Bates commented that the interoperability between eHealth applications and seamless and reliable clinical information exchange is a key to making EHR use a cornerstone of practice . Even ifLegal and regulatory changes can be required to address eHealth adoption related issues ,132. ForIn this 4-step literature review, 40 factors were identified to be influential to health care providers’ acceptance of eHealth and organized in accordance with the UTAUT model. The findings may help decision makers at health care settings and policy makers at the health sector to better understand eHealth adoption issues and take action to facilitate the eHealth innovation process. Our work also suggests further studies to extend theories on information technology adoption.


The modalities of HIV, HBV, HCV healthcare-associated infections and the underlying social and cultural logics contributing to this transmission are not precisely known, since hospital hygiene has mainly been studied from a biological point of view until now. However, hospital hygiene is shaped by norms and social-cultural representations, which increase or limit the transmission of infectious agents, always taking place within social relations. In 2006-2009, an anthropological research project (ANRS 12102) aimed at documenting those issues in various health settings in Cambodia. Practices related to hygiene were analyzed from a cultural point of view, especially since norms are interpreted at local level according to social and symbolic logics.We collected qualitative data in formal and informal sectors of care, mainly in general hospital services, maternity wards, primary health centers and in traditional practitioners’ private clinics. We interviewed many participants regarding hygiene practices and social relationships amongst the staff and between health care workers and patients. We also investigated the local representations of hygiene, their impact on the relationships between health care workers and patients and perceptions of transmission risks by health care workers.In a context were hygiene practices were limited by the lack of adequate materials and equipments, other factors were identified, which influence and distort hygiene practices. They include: (1) informal and formal social relationships in hospitals, (2) major infection control roles played by cleaners in absence of professional acknowledgment, (3) lack of consideration for hygiene by health professionals that rely on low-ranking staff for hygiene practices. Besides these issues, various questions emerged regarding social science theory. Indeed, doing research on infectious disease transmission led us to include investigations and interpretations related to anthropology of development, historical and social perspectives on public health institutions, and social organization in hospital settings. The social condition of working class (the workers), the legal and illegal systems of care, various aspects related to the politics of reproduction were issues at stake, which leads to more general issues on social changes in Cambodia. Moreover, hygiene issue may be seen as an encounter of the biological body and the social body, whose construction and effects are deeply inscribed in the historical and contemporary forms of social organization and power distribution in Cambodia.Our anthropological findings illustrate the importance of comprehensive understanding of hygiene practices; they need to be considered when designing intervention to improve infection control practices in a Cambodian medical setting.


A causal link between the increasing environmental pollution and the fast spreading of allergic diseases is currently discussed.The exogenic and endogenic noxious agents contributing to the total environmental load are primarily acting through immunotoxic, sensitizing and neurotoxic mechanisms in animal experiments and in humans. Beside classic allergic–triggering factors , the adjuvant role of environmental pollutants gains increasing importance in allergy induction.Our therapy experience with more than 18.000 atopic eczema patients shows that beside allergic reactions pseudoallergic mechanisms through toxic environmental agents  are increasingly incriminated as causal factors for the complex symptomatology.The avoidance and elimination of such triggering factors before and during pregnancy and in early childhood may result in a significant decrease of the incidence of atopic diseases. More than 50,000 are used daily. They contribute to the environmental load of the air by exhaust fumes  of cars, industrial factories and power stations, industrial dust, excess of ozone as well as the chemical burden of soil and water with pesticides, fertilizers, insecticides, heavy metals and chemical or radioactive residues. Virtually no one can avoid over longer time the negative effects of different toxins like asbestos, formaldehyde, wood preservatives, adhesives, oils, petrol and solvents, resins, detergents and heavy metals. Besides, daily intake of fast food products may cause various side effects through preservatives, dye–stuffs, binding substances, gelatines, emulsifiers and taste intensifiers giving our food a long stability, an appetizing appearance and the desired taste. Cosmetic ingredients, drugs and pharmaceutical products as well as dying–stuff and synthetic materials of the textile industry are also potential triggers of intolerance reactions.We may actually count more than 7×10exogenous environmental challenge.Furthermore, allergic and chemical sensitive patients frequently react upon exposure to electromagnetic fields of different electrical equipments like PC's, TV, HiFi– and other house devices, antennas and power lines as well as to radioactive residues from environmental and medical sources. The burden of the daily psycho–social stress (distress) added to the above factors, makes a first sum–up of the body's load through endogenous factors also contributing to a toxic cumulative raise of the oxidative stress. American authors introduced some years ago the term ‘Total Environmental Load’ as standard for the body's total burden through pollutants . Hi. Hi64]. Further inhibitory factors are food additives, heavy metals, alcohol and nicotine, whereby alcohol additionally leads to an increased absorption of biogenic amines from the intestinal tract. Some drugs, for example certain antidepressants, act as MAO blocker as well. On the other side, the cofactors for MAO (iron and FAD) are decreased in AE patients, the cofactors for DAO  are nearly normal, suggesting excesses of the enzyme inhibitors mentioned above .These findings explain the pseudoallergic, non–immunological mediated reactions against certain foods like frozen fish containing 10 times higher histamine levels than fresh fish. In different varieties of blue cheese, sour cabbage, pickled cucumbers or ketchup high concentrations of histamine can be found, too. Pseudoallergic reactions against other biogenic amines like tyramine, octopamine, phenyl ethylamine or putrescine may also happen because splitting enzymes like MAO and DAO are inhibited or lacking. High concentrations of the biogenic amin tyramin are found for instance in sausages, beer, red wine, champagne and certain varieties of cheese.The increased intestinal permeability in atopic patients enables a significantly raised antigen absorption which in turn leads to higher levels of circulating immune complexes, activation of the complement system and of the coagulation cascade and to the IgE mediated degranulation of the granulocytes and basophiles . HoweverThe reason for the increased intestinal permeability  lies in E. coli, Klebsiella sp., Proteus sp., Clostridium sp. and fungi like Candida or Geotrichum sp.  produced by a putrefactive flora  are also increasing the irritability of the skin, mucosa and nervous system and act as adjuvant factors (e.g. phenols) for the induction of the IgE synthesis (Freund's adjuvant).By fermentation, different intestinal yeast and bacterial strains transform the ingested carbohydrates in organic alcohols  and shorTherefore the identification and elimination of chronic microbial foci of the skin, lungs and especially of the gut is essential for a successful therapy in atopic patients.Further side–effects of a disturbed intestinal flora were discussed in detail in a former study . The reIn the last years it was more and more reported about the immune– and allergotoxic relevance of heavy metal burden  ,42–45.Mercury plays a specific role, even because of the intensive discussion about ‘amalgam’. It is important to divide between the allergic potential of mercury  and his chronic–toxic potential leading especially in allergic patients to an accelerated summation effect with other pollutants.Some examples of several mechanisms for the attack are referred:Binding to serum and cell proteins  with interactions in the intermediary metabolism .Rise of the cellular mitosis rate in lymphocytic populations .Induction of the IgE–synthesis with increase of the allergen specific IgE–answer in rats .Decrease of total T–lymphocytes, T–helper cells and natural killer cells after mercury release from amalgam fillings ,48.Stimulation of inflammatory reactions by activation of the corresponding enzymatic systems (for example collagenases ).Candida albicans) [Exceptionally important for patients is the transformation of the ionisized Hg2+–form through methylation in a more toxic, lipid soluble organic compound (methyl mercury) . Oral anlbicans)  accomplAlthough the clinical relevance of these results for the pathogenesis of atopic eczema is still controversial, the most important mercury sources remain always the same: as addition in different drugs , fish–rich food, entrails (0.3–2.3 micro g/day) and especially amalgam fillings (3–17 gamma g mercury vapour/day ).Mercury possesses an evident affinity for the epithelial cells of the gastrointestinal tract  and the skin, for hair, thyroid gland, liver, pancreas, kidneys and the brain  –54. SpinOur own investigations in atopic eczema, urticaria and psoriasis patients show by means of the so–called ‘chewing–gum test’ a considerable metal release, directly correlating to the number of fillings . This phAccording to our experience with over 18,000 allergic skin patients two facts are certain:Dentists drill work in the amalgam fillings of allergic patients without appropriate protection  generally lead to a rapid worsening of the symptoms, andTherapy resistant, recurrent atopic eczema of the head, neck and face skin as well as chronic rhinitis and pharyngitis greatly improve or subsides after the removal of amalgam fillings followed by adequate mobilisation procedures .Important preventive steps for allergic patients may already be accomplished in pregnant women, whereby the avoidance of strong allergens in food, alcohol, nicotine and exogenic toxins can lead to a decrease of the baby's atopic risk . Also thAn allergen-poor diet offered in a rotation system, together with the clearing of microbial foci, toxin mobilisations, immunmodulation and psychological care are important promoters of a long–term recovery ,60.Main therapy steps in atopic patients may therefore include:Immediate compensation of the redox and free radical status of the blood.Elimination of pathogenic germs of the skin, mucosa, respiratory system, urinary tract and intestine.Restoration of a healthy intestinal flora and function, by means of antimycotics, plant extracts, appropriate food and lactic acid producing bacteria.Reduction of increased levels of pathogenic substances in blood as biogenic amines, endotoxines, pathogenic antibodies and circulating immune complexes.Specific or unspecific modulation of the humoral and cellular immune function by intake of immunoglobulines, selected thymus extracts and other biological agents.Modulation of neurohormonal imbalance Activation of the detox systems of the liver and blood .Compensation of deficits of vitamins, minerals, trace elements, amino acids, enzymes, essential fatty acids and energetic substances by appropriate substitution therapy.Preparation of appropriate diet plans considering the individual allergic and pseudoallergic intolerance reactions.Dietary treatment: Based on the individual spectrum of food intolerances, there is no ideal diet plan for all atopic patients. An extensive panel of diagnostic procedures for allergic and pseudoallergic reactions against food antigens and additives is therefore imperative before completing a diet plan. These include detection of food allergens by means of specific IgE and IgG4 antibodies, histamine and free radical release before and after challenge with foods or additives, identification of lactose, fructose or sucrose intolerances as well as pseudoallergic reactions resulting from microbial fermentation/putrefaction processes in the gut.When we investigate the complexity of the atopic disease than it is easily comprehensible that a symptomatic therapy with cortisone, radiation or antihistamines gives hardly a chance for a long term recovery.On the contrary, a functional concept should include a targeted diagnosis of individual deviations in the intermediary metabolism, immunological state and nutrition status to offer the appropriate therapeutically steps. The long lasting recovery achieved in more than 80% of all cases justifies this integrative therapy concept and won the acceptance of physicians, patient organisations and all health insurances who integrated the clinic in the official German health system.


The One Health paradigm for global health recognizes that most new human infectious diseases will emerge from animal reservoirs. Little consideration has been given to the known and potential zoonotic infectious diseases of small companion animals. Cats and dogs closely share the domestic environment with humans and have the potential to act as sources and sentinels of a wide spectrum of zoonotic infections. This report highlights the lack of a coordinated global surveillance scheme that monitors disease in these species and makes a case for the necessity of developing a strategy to implement such surveillance. Increasingly, the concept of One Health is recognized as a valuable paradigm for global health management. One Health is an initiative that seeks greater integration of human and veterinary medicine in areas as diverse as infectious disease control and comparative and translational medical research. A major focus of One Health has been on infectious diseases shared by humans, production animals , companion animals, and wildlife in the context of ecosystems and the physical environment. An area of One Health that has garnered much attention has been the emergence or reemergence of infectious disease, and the finding that ≈75% of newly reported human infections have emerged, and are therefore likely to continue to emerge, from an animal reservoir  disease  or utilitarian purposes , They might be bred or wild caught with the intention of keeping them in the domestic environment. In some cultures, certain companion animal species also provide a food source. Companion animals encompass a spectrum that includes arthropods, caged birds, cats, chinchillas, dogs, ferrets, fish, guinea pigs, hamsters, horses, mice, poultry, rabbits, rats, and reptiles. This review focuses on the 2 major small companion animals: the domestic cat and dog.,Over millennia, cats and dogs have played an integral role in many aspects of human life. Human–companion animal interactions have a wide range of benefits to human health. These benefits include social development and improved quality of life associated with companionship, and inspiration afforded by pets (www.avma.org/reference/marketstats/ownership.asp). In the United Kingdom, an estimated 8–10 million pet dogs live in 22%–31% of households, and the same estimated number of pet cats live in 18%–26% of households (www.pfma.org.uk/pet-population-2011/).It is difficult to enumerate accurately the populations of pets kept in households in industrialized countries. Most recent estimates in the United States suggest that there are 72 million pet dogs kept by 37% of households and 81 million pet cats kept by 32% of households  transfer of pathogens. This association might be particularly likely for free-roaming animals in rural areas, but it is also possible for pets in urban areas where there is potential for interchange of infectious agents between cats and dogs and wild animals such as raccoons, opossums, urban foxes, and wild rodent species.Staphylococcus aureus . These are life-threatening human infections for which the domestic dog is the primary reservoir and for which control of the disease in the dog has the greatest benefit for human health . Coverage ranges from infectious diseases to chemical exposures. GPHIN searches global media for relevant information and extracts content for review by analysts. Outbreaks identified by GPHIN feed into the Global Outbreak Alert and Response Network and the Global Early Warning and Response System, which bring together institutions such as the Food and Agriculture Organization, the World Organisation for Animal Health (OIE), and WHO and tap into a network of institutions and organizations available to provide resources and expertise in response to such alerts (www.who.int/csr/outbreaknetwork/en/). ProMed-mail, a program of the International Society for Infectious Diseases, is a similar data-searching resource (www.promedmail.org) that rapidly disseminates information.The Global Public Health Intelligence Network (GPHIN), managed by the Public Health Agency of Canada and developed with the support from the World Health Organization (WHO), is a fee-based aggregator service for subscribers (http://web.oie.int/wahis/public.php?page=country_zoonoses). Rabies and leishmaniasis are reported into WAHID. Control of rabies, in particular, benefits from strong linkages between animal and human surveillance in industrialized countries. However, integrated surveillance for zoonoses is uncommon; only 19% of zoonoses surveillance systems cover humans and animals , which captures specified zoonotic human infections reported annually by member countries (www.cdc.gov/ncezid/dpei/eip/) at the Centers for Disease Control and Prevention coordinates population-based laboratory surveillance programs, some of which are relevant to transmission of zoonoses from companion animals. These programs include the Active Bacterial Core surveillance for invasive bacterial disease and the Foodborne Diseases Active Surveillance Network (FoodNet) for foodborne diseases caused by selected bacterial and parasitic pathogens. Surveillance of influenza in humans occurs at global, regional, and national levels. For example, WHO coordinates a network of 111 national influenza centers in 83 countries, which are supported by 4 regional reference laboratories  information of global health concern.Recently, OIE has expanded surveillance of wildlife disease by collating data from member countries and providing an overview of disease events and pathogens in these species. Data collection through WAHID enhances dissemination of this information.In comparison with human and livestock diseases, none of the international health agencies are mandated to coordinate surveillance of diseases in companion animals. In addition, surveillance systems exist for only a few of the small animal zoonoses .An estimated 55,000 persons die each year of rabies, primarily because of dog bites and subsequent infection with canine rabies, in resource-poor areas of Africa and Asia. The effects of rabies are considerably less in industrialized countries, which might be attributed to widespread compliance with mandatory dog leash laws, vaccination, and resulting high vaccination coverage.In developing nations, problems relate to surveillance and control, and there is a lack of diagnostic capacity, misdiagnosis, poor incentivization, difficulties of communication (within and between sectors), and logistical and financial constraints. Despite being one of the most serious and frequently fatal zoonoses, rabies is still underreported throughout the developing world, and 100-fold underreporting of human rabies is estimated for most of Africa  reservoir of the parasites. This disease is endemic to the Mediterranean basin, Middle East, and South America and is emerging within non–disease-endemic areas because of transportation of dogs from disease-endemic areas, expansion of the geographic range of free-ranging wildlife reservoir species and sandfly vectors because of climate change, and human incursion into previously uninhabited wildlife ecologic niches .Visceral leishmaniasis (VL), including ZVL and anthroponotic visceral leishmaniasis caused by Measures established for the global surveillance and control of this major infectious disease have been reviewed  virus (H5N1) infection in domestic cats and zoo felids fed virus-infected chickens  outbreaks, domestic cats are at risk for disease or death from HPAI virus (H5N1) infection, and that unusual deaths of cats in areas at risk for HPAI virus (H5N1) infection might act as a warning signal for presence of the virus. Domestic cats might also have a role in the epidemiology of HPAI virus (H5N1) infection in poultry, humans, and other species. Surveillance in HPAI virus (H5N1)–endemic areas should include felids and other carnivores showing unusual illness or deaths (During influenza A(H1N1)pdm09, multiple instances of companion animal  infection with influenza A(H1N1)pdm 09 virus were confirmed by laboratory testing  was transmitted to racing dogs in Florida, USA  collate and disseminate relevant information.The public health role of many zoonotic agents of small companion animals is underrecognized or poorly understood by medical and veterinary health care providers and pet owners. Furthermore, small companion animals might play a major role in potential zoonoses of the future, either by acting as a reservoir or as an intermediate host. Information about known and potential zoonoses associated with cats and dogs is emerging rapidly and needs to be more efficiently disseminated. Two examples of emerging zoonoses are the arthropod-transmitted rickettsioses and bartonellosis . The preRickettsia rickettsii) in newly emergent areas , and dogs have been used effectively as proxies for risk for human spotted fever rickettsioses . In the United Kingdom (http://uk.cicadasurvey.com/) and Australia (www.diseasewatchdog.org/index.php/login), 2 veterinary vaccine manufacturers have introduced simple sentinel practice-based reporting schemes for canine and feline infectious diseases. These data provide proof-of-principle for the sentinel practice concept. In the United Kingdom, the Small Animal Veterinary Surveillance Network scheme has shown the feasibility of using shared practice record-keeping software to enable veterinarians to input data related to disease diagnoses made in their practices .To highlight the issues surrounding this area, the World Small Animal Veterinary Association (WSAVA) has recently formed a One Health Committee, and the present position paper has arisen from discussions held by this committee. The WSAVA One Health Committee draws together expertise in companion animal infectious disease research, and 1 goal of this committee is to enhance understanding of the infrastructure required for effective integrated global infectious disease surveillance , or should responsibility be placed with the pet owner  or the industry  that generates income from the keeping of pet animals or breeders that raise and sell these animals? Although a plan for pet owners and industry to take responsibility might be feasible in more affluent industrialized nations, it would be unlikely to be effective in developing nations. Alternatively, a cost-sharing model might be considered in which surveillance becomes a public–private partnership. These are not simple questions, but the first stage in this process is recognition of the problem by those in authority and the brokering of discussions between interested parties. We hope that this report might define historical and evolving facts and thereby prompt such discussions in the near future.


Current estimates suggest an HIV prevalence of 42% among people who inject drugs (PWIDs) in Dar es Salaam, while HIV prevalence is estimated to be 8.8% among the general population in the city. To address the HIV epidemic in this population, the government of Tanzania began establishing HIV prevention, treatment and care services including outreach and medication assisted treatment (MAT) for PWIDs in 2010. We assessed gender inequities in utilization of outreach and MAT services and evaluated differences in HIV risk behaviors between female and male PWIDs.Routine outreach data between December 2010 to mid-August 2012 and baseline data on clients enrolling in methadone from February 2011 to August 2012 were utilized. Binomial regression was used to estimate adjusted relative risk estimates comparing females to males.From December 2010 to August 2012, 8,578 contacts were made to drug users; among them 1,898 were injectors. A total of 453 injectors were eligible and referred to MAT, of which, 443 enrolled in treatment. However, regarding total outreach contacts, outreach to PWID, referral to MAT and enrollment in MAT, 8% or less of drug users accessing services were women. In contrast, weighted estimations from surveys suggest that 34% of PWIDs are female, and this approximation is similar to recent population size estimations. Overall, 43% of traditional outreach workers conducting outreach with drug users were female. Though reporting higher levels of condom usage, female PWID were more likely to report multiple sex partners, anal sex, commercial sex work and struggle under a higher burden of addiction, mental disorders and abuse.Services have not been mobilized adequately to address the clear needs of females who inject drugs. A clear and urgent need exists for women-centered strategies that effectively engage female PWID into HIV prevention services. In the mid-1980s, East Africa became an important stop along international drug trafficking routes thereby introducing heroin in the region HIV/AIDS has long been linked to injection drug use, a major driver of the HIV epidemic in many countries in Asia, the Middle East and Eastern Europe Concurrently in sub-Saharan Africa, gender inequities lead to a higher burden of HIV among women as 58% of people living with HIV in sub-Saharan Africa are females, and girls and young women aged 15–24 are 2.4 times more likely than their male counterparts to be HIV-positive In addition to increased risk for HIV, female PWIDs face higher levels of stigma, stronger barriers to accessing services and fewer services that are tailored to their needs In response to the HIV epidemic among people who inject drugs in Dar es Salaam, the government of Tanzania, namely the Ministry of Health and Social Welfare (MoHSW), Muhimbili University and Hospital of Allied Sciences (MUHAS) and the Drug Control Commission (DCC), in partnership with Pangaea Global AIDS Foundation (Pangaea) and with funding from the US Centers for Disease Control (PEPFAR) launched the first publically funded medication assisted treatment (MAT) program in mainland sub-Saharan Africa at Muhimbili National Hospital. In addition, community-based outreach services for drug users were implemented by this consortium with support from the University of Texas-Houston.Community-based outreach to drug users was initiated in 2010 through four community-based organizations (CBOs) located in Kinondoni district utilizing three basic approaches: 1) traditional outreach workers who were non-drug using social workers or health professionals; 2) storefront drop-in centers providing information, education and communication (IEC) for HIV risk reduction; syringe cleaning kits; psychosocial services for individuals, families and groups, livelihood and skills training, nutritional support and a venue for 12-step programs; and 3) two mobile units offering HIV testing and counseling (HTC) in drug using communities in Dar es Salaam, Tanzania. Initial outreach was conducted by outreach workers, where clients could be referred to neighborhood storefront drop-in centers for additional care. On a weekly basis, the mobile HTC units coordinated with outreach workers from each of the CBOs to identify locations and times for HTC where the CBOs operate, and outreach workers canvas in the area surrounding the mobile unit. Individuals who tested positive for HIV through mobile HTC units were referred to receive HIV care and treatment at Muhimbili National Hospital or Mwananyamala Regional Hospital.In February 2011, the first public medication assisted treatment (MAT) clinic on the mainland of sub-Saharan Africa, offering methadone, was launched at Muhimbili National Hospital in Dar es Salaam. Enrollment into the MAT program required referral from a community-based organization. In order to be eligible for MAT, individuals had to exhibit opioid dependence, have evidence of recent drug injection and a positive urine screening for opiates. Before referral to MAT, individuals were also required to attend a series of educational sessions on HIV, STIs, medication adherence, and supportive services provided by CBOs. Once enrolled in MAT, methadone was provided to clients seven days a week at the clinic as a directly observed therapy.Study subjects were patients who received community-based outreach services from the four CBOs operated by the Tanzanian AIDS Prevention Program in Kinondoni district from December 2010 to mid-August 2012. In addition, study subjects included those who enrolled into the methadone program from February 2011 to August 2012 at Muhimbili National Hospital. In our analysis comparing risk behaviors between male and female PWIDs initiating methadone (see below), we included the first 400 clients with completed baseline assessments.The study utilized electronic databases from the four CBOs and the MAT clinic at Muhimbili National Hospital. CBO and clinic management personnel primarily used these databases as tools for clinical management and routine monitoring and evaluation. For community-based outreach services, demographics, drug using behaviors and injection- and sexual-related HIV risk behaviors were collected on all individuals during their first outreach encounter via a brief questionnaire. Clients who enrolled into MAT were asked to complete a comprehensive baseline survey - including modified components of the Addiction Severity Index and Johns Hopkins Symptoms checklist for anxiety and depression - to collect demographic, drug history, legal history, mental health, and HIV risk behavior data. In September of 2012, the databases were collected for the purposes of this evaluation.The patient-level characteristics utilized in our study from the CBO database included demographics: age (in years), sex  and education level; sex related risk factors: multiple sex partners in the last month , anal sex in the last year, commercial sex work and condom use at last sexual encounter; and injection-related risk factors: shared needles at last injection, shared other equipment at last injection and polysubstance use . Additionally, the number of outreach contacts with drug users, number of contacts with PWIDs and number of referrals for MAT were also extracted from the CBO database.The patient characteristics used from the MAT electronic data system included demographics: age (in years), sex  and education level; sexual risk factors: multiple sex partners in the last 6 months  and regular condom use in the last 6 months ; injection risk factors: flashblood - a syringe full of blood drawn back immediately after injection and shared with a companion to inject Our primary exposure of interest was the sex  of outreach and MAT clients. Our outcomes for the study included sexual and injection risk factors from clients accessing community-based outreach and sexual and injection risk factors, mental health and abuse history from medication assisted treatment clients. Binomial regression was used to estimate adjusted relative risk estimates comparing females to males with regards to study outcomes. Potential covariates considered as confounders included education and age. Covariates that were significant at p<0.25 in bivariate analyses were included in the multivariable models to control for confounding.For estimation of the expected proportion of women PWIDs in outreach and MAT services, we utilized the breakdown from population size estimations and calculated a weighted average of the proportion of female PWID participating in three community-based surveys. The weights were proportional to the total size of the survey. All statistical analyses were conducted using Stata v11.2 .Given the use of programmatic data delinked from personal identifiers, this study was approved as nonhuman subjects research by the US Centers for Disease Control and Prevention and Institutional Review Board of Ethical and Independent Review Services. Data will be made freely available upon request.A total of 1,898 outreach contacts were made with people who inject drugs between December 2010 and August 2012, 47 of which had missing information regarding the client’s sex . Among tDifferences between female and male PWIDs with regards to reported sex-related and injection-related HIV risk behaviors are presented in Between December 2010 and August 2012, 8,578 outreach contacts were made with drug users, of which 1,898 (22%) were with PWID. Overall, 453 were referred to the MAT clinic at Muhimbili National Hospital. A total of 443 (98%) initiated treatment and 376 were retained in the program at 30 days after initiation . On averA total of 400 MAT clients were enrolled between February 2011 and August 2012, with the majority of enrollees (92%) being male. The average age was 34 years at enrollment, while males tended to be older on average compared to females  vs. 29 yrs ; p<0.001). Female and male enrollees were not significantly different in education  vs. 59% ; p = 0.97), marital status  vs. 9% ; p<0.50), or criminal history  vs. 56% ; p<0.75).Differences in HIV risk, mental health and history of abuse between male and female MAT clients are outlined in With data from 1,851 PWIDs receiving community-based outreach services and 400 clients accessing medication assisted treatment at Muhimbili National Hospital, we evaluated for inequities in service utilization between males and females who inject drugs and differences in HIV risk behaviors between male and female PWIDs utilizing services in Dar es Salaam, Tanzania. Compared to population estimates, our assessment identified substantial disparities in women accessing both community-based outreach and MAT services in this study population. Concurrently, female PWIDs face higher levels of sex-related HIV risk behaviors, anxiety, depression and history of sexual abuse. Further implementation science initiatives are critically needed to strengthen harm reduction services to better address the needs of female PWIDs.The lack of access by women is particularly concerning given the high levels of HIV risk in this population. Female PWIDs face higher levels of sex-related HIV risk behaviors such as anal intercourse placing their sexual risks higher than men who have sex with men since they are engaging in the highest risk sexual behaviors as well as drug injection. Ongoing sexual risks are likely the result of utilizing sex as a means to obtain either drugs or money to support their heroin use or to provide for basic food and shelter. These women are clearly at risk of violence and report higher levels of sexual abuse, with anecdotal reports of physical and sexual violence in this population The lack of female engagement in HIV prevention services remains a serious concern for overall HIV prevention in Dar es Salaam because female PWIDs engage in sexual intercourse with non-drug users in an effort to obtain resources. With HIV prevalence over 60% among female PWIDs Programs that have directly addressed the needs specific to women have shown to be effective in other contexts Historically, community-based outreach services targeting PWID in Dar es Salaam have utilized traditional outreach workers who were non-drug using social workers or health professionals to outreach to drug using communities. Most of the outreach has focused on reaching drug users in regular hangouts, often referred to as a ‘maskani’, during the day. ‘Maskani’ are open air spaces where groups meet, oftentimes hidden from the general public and police In addition to impacting outreach contacts, the daily schedule of women who are engaged in sex work or have domestic responsibilities is also an important factor in considering the timing of HIV prevention services at fixed locations. The standard daytime operating hours of the MAT clinic and community-based drop-in centers and their locations present obstacles to many women who do not have sufficient time to travel, especially when relying on public transport, given their other responsibilities. Extending the operating hours of drop-in centers and the MAT clinic to accommodate these schedules is a feasible intervention that could increase women’s engagement. In addition, all or part of the extended hours could specifically cater and have restricted access for female PWIDs, creating a safe space away from men. This strategy could be particularly important to consider as female PWIDs are at increased risk of sexual assault, and physical and sexual violence by male PWIDs has been reported The principal limitation of our study was due to the observational nature of the research. Although we adjusted for measured patient characteristics to address concerns of confounding, the potential for unmeasured or mismeasured factors to bias our results existed. Regarding the proportion of females expected among people who inject drugs, we pooled data from recent surveys that relied on convenience sampling to build their study population. People who inject drugs are a marginalized population and gathering population-based estimates, disaggregated by sex, can be a challenging endeavor. It is possible that the percentages of female PWIDs expected is an overestimate possibly due to the sampling approaches not yielding a representative sample of the overall population or to female PWIDs experiencing high mortality rates since the surveys were conducted along with a low incidence of new females initiating drug injection. Conversely, it is also important to remember that female PWIDs often face more stigmatization and marginalization than their male counterparts, furthering the difficulty of accurately estimating the proportion of PWIDs who are female as population size estimations often underestimate parts of most at risk populations that tend to be more hidden Despite the reality that female PWID are at higher risk of HIV and struggle under a higher burden of polysubstance use, sexual risk taking, anxiety, depression, sexual violence and discrimination, services have not been mobilized adequately to address the clear needs of these women. With a high prevalence of HIV and ongoing sexual risk taking, the HIV epidemic could easily expand outwards from these female PWIDs to their sexual partners, destabilizing the heterosexual HIV epidemic in Dar es Salaam. It is clear, therefore, that an urgent need exists for women-centered HIV prevention services that effectively target female PWID. Successful interventions for this high risk population will yield benefits to the women who are in desperate need of assistance, and to the larger HIV epidemic in Dar es Salaam.


Computer simulation offers the ability to compare diverse interventions for reducing cardiovascular disease risks in a controlled and systematic way that cannot be done in the real world.We used the Prevention Impacts Simulation Model (PRISM) to analyze the effect of 50 intervention levers, grouped into 6 (2 x 3) clusters on the basis of whether they were established or emerging and whether they acted in the policy domains of care , air , or lifestyle . Uncertainty ranges were established through probabilistic sensitivity analysis.Results indicate that by 2040, all 6 intervention clusters combined could result in cumulative reductions of 49% to 54% in the cardiovascular risk-related death rate and of 13% to 21% in risk factor-attributable costs. A majority of the death reduction would come from Established interventions, but Emerging interventions would also contribute strongly. A slim majority of the cost reduction would come from Emerging interventions.PRISM allows public health officials to examine the potential influence of different types of interventions — both established and emerging — for reducing cardiovascular risks. Our modeling suggests that established interventions could still contribute much to reducing deaths and costs, especially through greater use of well-known approaches to preventive and acute clinical care, whereas emerging interventions have the potential to contribute significantly, especially through certain types of preventive care and improved nutrition. A Public Health Action Plan to Prevent Heart Disease and Stroke (http://millionhearts.hhs.gov/index.html).Heart disease and stroke are the first and fourth leading causes of death in the United States  despite d Stroke  and highGuide to Community Preventive Services  to compare established and emerging prevention interventions across the 3 domains of care, air, and lifestyle, in terms of their potential for reducing the adverse consequences of cardiovascular disease (CVD) risk factors in the US population through the year 2040. This analysis can help inform the policy conversation about what kinds of prevention and care-based interventions are most useful for addressing CVD –17.PRISM is a nationally representative computer model that simulates the effects of diverse clinical and population-level interventions aimed at reducing risks for CVD events  and for other chronic conditions and diseases  ,18,19. IIn PRISM, the population is segmented by 6 childhood and adult age categories, by sex, and by CVD event status . The model simulates changes in the population through birth, death, migration, aging, and movement from non-CVD to post-CVD status. It also depicts flows into and out of 3 blood pressure categories , 3 blood cholesterol categories , 3 blood glucose categories , 4 smoking categories , and 2 body mass index categories . PRISM also includes risk factors of poor nutrition , inactivity, psychological distress, secondhand smoke, periodontal disease, sleep apnea, small particulate air pollution, and inadequate use of aspirin for primary prevention. Co-occurrence of these risk factors in individuals is not modeled explicitly , but interactions among the risk factors are represented algebraically in equations for cardiovascular events and deaths and also in equations describing how the prevalence of one risk factor  may affect another . The model simulates changes by quarter-year increments in more than 4,000 variables, including changes in population mix, risk factor prevalence, and risk factor–related morbidity, mortality, and costs .The current version of PRISM, version 3p, includes 50 intervention levers that may prevent or mitigate the cardiovascular risks described above. All interventions in the model are based on peer-reviewed literature and discussions with experts working in the field who helped to specify and quantify their potential effects .We grouped PRISM’s 50 intervention levers into established and emerging interventions that we crossed with policy categories of care , air , and lifestyle , resulting in 6 clusters . For eacWithin the care policy domain, the established interventions include the use of quality preventive care for diagnosis and basic control  of high blood pressure, high cholesterol, and diabetes; quality acute and rehabilitative care after cardiovascular events; quality care for post-CVD patients to prevent recurrent events; behavioral services for smoking cessation and weight loss for the obese; mental health services to address psychological distress and depression; diagnosis of sleep apnea and its effective treatment through the use of continuous positive airway pressure (CPAP) devices; prevention of periodontal disease through regular dental care; and the use of aspirin for primary prevention among middle-aged and older people  who have not had a cardiovascular event. Emerging care interventions include tighter control  of high blood pressure, high cholesterol, and diabetes and the control of borderline hypertension, borderline cholesterol, and prediabetes.Within the air domain, the established interventions include several policies for tobacco: taxation, counter-marketing, and prohibitions on workplace smoking. Emerging interventions in the air domain are tobacco marketing restrictions and the reduction of small particulate  air pollution. Although the sources of PM 2.5 are well understood and reductions of 50% or more were achieved from 1990 to 2010, no consensus exists on how to accomplish further reduction as a matter of national policy .Within the lifestyle domain, the established interventions consist of policies for increasing access to and promoting physical activity for adults and older children. Emerging interventions in this domain include strategies to reduce sodium and trans fat consumption (through legislative or market-based actions), the taxation and counter-marketing of energy-dense (junk) food, improving physical activity in child care, and policies for increasing access to and promoting the consumption of fruits and vegetables.In this analysis, we report the results of testing these 6 clusters one at a time and in combination. When an intervention lever was included in a cluster being tested, it was ramped up linearly to a level of best plausible implementation from 2012 to 2017 and remained in full effect thereafter to the end of the simulation in 2040. For some of the interventions (whether established or emerging), the best plausible lever setting was directly measurable , whereas for others it was defined as 100% of an ideal or best practice as described in the literature or by subject matter experts.We report annual outcome variables that include preventable deaths per thousand adults (death rate) that include CVD deaths and non-CVD deaths attributable to CVD risk factors, such as chronic obstructive pulmonary disease, end-stage renal disease, and various cancers ; years of potential life lost per thousand adults; 3 categories of per-adult cost ; and the sum of these per-adult costs . Costs wTo test the robustness of results, each of the 6 cluster intervention scenarios was tested by using probabilistic sensitivity analysis. In 200 Monte Carlo runs of PRISM, 89 different parameters quantifying intervention effect sizes were set to randomly selected values along assumed uniform probability distributions with estimated mean, minimum, and maximum. These distributional parameters were taken from means and confidence intervals reported in the research literature where available and otherwise from the estimates of subject matter experts .We calculated cumulative results from testing the 6 intervention clusters  from 2012 to 2020 . Of the The air and lifestyle interventions had modest effects through 2020. The combined air interventions led to modest reductions in the death rate  and combined costs . The health and cost effects were evenly divided between the established and emerging air interventions. The combined lifestyle interventions provided greater reductions in the death rate  and combined costs . The emerging lifestyle interventions contributed more than the established interventions did.The combined care, air, and lifestyle interventions resulted in large reductions in the death rate  and a moderate reduction in combined costs . Both established and emerging interventions contributed to these reductions, but the established interventions contributed more than the emerging ones did with respect to health effects, while the emerging interventions contributed more than the established ones did with respect to total costs.We calculated cumulative results from testing the 6 intervention clusters from 2012 to 2040 . The comThe combined air interventions resulted in moderate reductions in the death rate  and combined costs . Both established and emerging air interventions contributed to these improvements, but the established air interventions contributed more than the emerging ones did.The combined lifestyle interventions resulted in moderate reductions in the death rate  and combined costs . Both established and emerging lifestyle interventions contributed to these improvements, but the emerging interventions contributed more than the established interventions did.The combined care, air, and lifestyle interventions resulted in large reductions in the death rate  and a moderate reduction in combined costs . Both established and emerging interventions contributed to these improvements, but the established interventions contributed more than the emerging interventions did with respect to health impacts, whereas the emerging interventions contributed more than the established ones with respect to total costs.Results from the probabilistic sensitivity analysis are represented in the uncertainty ranges , Table 3We used PRISM to compare the health and economic effects of established and emerging public health interventions in care, air, and lifestyle policy domains. Our testing suggests that established interventions may still have much to contribute to reducing deaths through greater use of well-known approaches to preventive and acute clinical care, whereas emerging interventions have the potential to contribute significantly through certain types of preventive care and improved nutrition . Considering all areas of intervention  together, emerging interventions have the potential to improve health significantly, but not by as much as further expansions in established interventions. The emerging interventions have the potential to reduce costs significantly, perhaps even somewhat more than the established interventions do, because they avoid large increases in the costs of risk factor management.The results reported here may be compared with those of other modeling studies, such as Kahn et al  and KottOur results are subject to several limitations. First, the simplified compartmental structure of PRISM means that it cannot capture certain detailed comorbidity effects and distributional effects that one might see in a microsimulation like Archimedes. The advantage of the compartmental approach is that a simulation can be performed in an instant, and thorough sensitivity testing of dozens of assumptions (as we have done here) thereby becomes practical ,20.Second, although PRISM does model changes in the age distribution of the population, it does not model changes over time in other demographic characteristics, such as race/ethnicity, urban/rural residence, or education and income levels. Nonetheless, the significance of such characteristics can be explored by calibrating the model to represent localities that are demographically different from the United States overall. Such calibrations have been performed with PRISM and suggest that the general findings here are unaffected by differences in demographics ,24.Third, although the combined costs calculated in PRISM included indirect productivity costs and several types of direct medical costs, including the direct costs of the model’s 34 care interventions, they do not include the implementation and enforcement costs of the model’s 16 air and lifestyle interventions. One study suggests that comprehensive population-level prevention  could be accomplished for $10 per person per year . This amFourth, the comparisons in this study have used certain outcome measures for deaths and costs. These are arguably good measures but others, such as cost per quality-adjusted life year, might yield different results. Fifth, as with all models, the PRISM estimates of effect sizes and other parameters are based on data and studies available at the time of model creation. As research evolves, some parameter estimates may become outdated. We have regularly updated PRISM to reflect the latest data and studies; the work presented here reflects a model update performed in November 2013.Despite these limitations, PRISM provides public health officials a unique analytic platform for examining the potential influence of different kinds of interventions, both established and emerging, for reducing CVD risks. Our modeling suggests that established interventions could still contribute much toward reducing deaths and costs through improvements in preventive and acute care, whereas emerging interventions have the potential to contribute significantly through other types of preventive care and improved nutrition.


Swaziland is the first country to introduce national early infant male circumcision (EIMC) into voluntary medical male circumcision (VMMC) programming for HIV prevention. With more than 5,000 EIMCs performed between 2010 and 2014, Swaziland learned that EIMC requires inclusion of stakeholders within and outside of HIV prevention bodies; robust support at the facility, regional, and national levels; and informed demand. Expansion of EIMC and VMMC has the potential to avert more than 56,000 HIV infections in Swaziland over the next 20 years. Swaziland is the first country to introduce national early infant male circumcision (EIMC) into voluntary medical male circumcision (VMMC) programming for HIV prevention. With more than 5,000 EIMCs performed between 2010 and 2014, Swaziland learned that EIMC requires inclusion of stakeholders within and outside of HIV prevention bodies; robust support at the facility, regional, and national levels; and informed demand. Expansion of EIMC and VMMC has the potential to avert more than 56,000 HIV infections in Swaziland over the next 20 years. The government of the Kingdom of Swaziland recognizes that it must urgently scale up HIV prevention interventions, such as voluntary medical male circumcision (VMMC). Swaziland has adopted a 2-phase approach to male circumcision scale-up. The catch-up phase prioritizes VMMC services for adolescents and adults, while the sustainability phase involves the establishment of early infant male circumcision (EIMC). Swaziland does not have a modern-day tradition of circumcision, and the VMMC program has met with client demand challenges. However, since the launch of the EIMC program in 2010, Swaziland now leads the Eastern and Southern Africa region in the scale-up of EIMC. Here we review Swaziland’s program and its successes and challenges.From February to May 2014, we collected data while preparing Swaziland’s “Male Circumcision Strategic and Operational Plan for HIV Prevention 2014–2018.” We conducted structured stakeholder focus group discussions and in-depth interviews, and we collected EIMC service delivery data from an implementing partner responsible for VMMC and EIMC service delivery. Data were summarized in consolidated narratives.Between 2010 and 2014, trained providers performed more than 5,000 EIMCs in 11 health care facilities in Swaziland, and they reported no moderate or severe adverse events. According to a broad group of EIMC program stakeholders, an EIMC program needs robust support from facility, regional, and national leadership, both within and outside of HIV prevention coordination bodies, to promote institutionalization and ownership. Providers and health care managers in 3 of Swaziland’s 4 regional hospitals suggest that when EIMC is introduced into reproductive, maternal, newborn, and child health platforms, dedicated staff attention can help ensure that EIMC is performed amid competing priorities. Creating informed demand from communities also supports EIMC as a service delivery priority. Formative research shows that EIMC programs should address the fears and anxieties of parents so that they, especially fathers, understand the health benefits of EIMC before the birth of their babies.The vast majority of public-sector facilities in Swaziland are led by nurses, and nurses and midwives have borne the brunt of caring for patients with HIV/AIDS in Swaziland. Like prevention of mother-to-child transmission, EIMC provides an opportunity for nurses and midwives to stand at the forefront of HIV prevention efforts. Rapid scale-up of VMMC and EIMC in Swaziland has the potential to avert more than 56,000 HIV infections and save US$370 million in the next 20 years. The hospital introduced the pilot to strengthen delivery of maternal and newborn health services. Data from the RFM Hospital pilot demonstrated the feasibility of implementing EIMC as an integral part of maternal and newborn care services in Swaziland. Factors contributing to the successful adoption of EIMC at RFM Hospital included hospital ownership of the intervention, effective communication with stakeholders, no severe adverse events, and collaboration with development partners to meet the start-up costs of training medical staff, facility improvements, and supplies.In October 2009, while the pilot was under way at RFM Hospital, the Swaziland MOH initiated planning for an EIMC program by hosting an international expert consultation on EIMC. Hosting the first consultation of its kind gave Swaziland a voice in the global discussion around EIMC. Swaziland’s MOH immediately moved forward on clinical and programmatic recommendations that emerged from the consultation. The resulting EIMC surgical guidelines endorsed the Mogen clamp as the preferred EIMC method for Swaziland. Less than a year after the consultative meetings, the MOH incorporated these guidelines into the existing national male circumcision surgical protocol.The timeline in Between 2011 and 2013, Swaziland expanded integrated EIMC services to 17 facilities.The MOH and stakeholders established EIMC within its national VMMC and HIV prevention program and integrated it into existing health service delivery outlets, namely the maternal, newborn, and child health (MNCH) service delivery platforms. The Swaziland EIMC experience offers a useful template for other countries with generalized HIV epidemics and low circumcision prevalence that are embarking on EIMC programming.We collected data during a consultation process with both VMMC and EIMC stakeholders between March and May 2014 in preparation for the document, “Male Circumcision Strategic and Operational Plan for HIV Prevention 2014–2018.” The drafting of this important guiding document offered a timely opportunity to reflect on the first years of EIMC program implementation and consolidate lessons learned.We collected data through structured stakeholder focus group discussions and in-depth interviews with key informants. We conducted 30 in-depth interviews with:Individuals from key MOH departments, including Central Medical Stores, the Public Health Unit, the Strategic Information Department, the Legal Advisor, the Swaziland National AIDS Program, the Rural Health Motivator Program, the Sexual and Reproductive Health Unit (SRHU), and the Expanded Program on Immunization (13 interviews)NGOs involved in EIMC service delivery and programming, including PSI, the Family Life Association of Swaziland, the Elizabeth Glaser Pediatric AIDS Foundation, and mothers2mothers (5 interviews)Professional associations, including the Swaziland Democratic Nurses Union, the Swaziland Nursing Council, and the Private Providers Association (3 interviews)Donors supporting EIMC programming (2 interviews)A traditional organization, Khulisa Umntfwana (“Grow a Child”)Providers and clinical managers working at 2 regional hospitals, 3 health centers, and 1 private clinic that offer EIMC (6 interviews with 5 doctors and 5 nurses). These were among the most informative interviews.We collected data through structured stakeholder focus group discussions and in-depth interviews with key informants.We selected stakeholders for in-depth interviews based on their involvement with MNCH or HIV/AIDS health issues from a policy or practice perspective, those with expertise in the Swazi health care workforce, and those with direct clinical or program experience with EIMC. While it was not feasible to visit all 17 facilities conducting EIMC services, we involved facilities from all 4 geographic regions of Swaziland as well as the varying types of facilities. Each interview lasted between 30 and 60 minutes, and we tailored them to informants’ areas of expertise: EIMC technical approach and service delivery, coordination, human resources, or communication and education.We convened 2 focus group discussions. Traditional leaders from Manzini Region attended the first discussion, which addressed cultural values related to EIMC, and optimal approaches to building informed community demand for EIMC. The second discussion, an MNCH stakeholders’ forum with 27 participants, included 10 EIMC-trained nurses and facility matrons representing facilities across all 4 regions, as well as other NGO and national MOH representatives. Forum participants broke into small groups to discuss questions of (1) provider support and staffing for MNCH services, including EIMC, (2) EIMC entry points and service coordination and linkages between VMMC and EIMC, (3) facility-based client education and counseling, (4) EIMC demand creation and community awareness, and (5) EIMC expansion and scale-up. Note-takers documented the focus group discussions, and we analyzed the notes for consistent themes. An implementing partner responsible for VMMC and EIMC service delivery contributed all service delivery data presented here: numbers of EIMC procedures performed by month, year, and location, as well as the incidence of documented moderate and severe adverse events. All data collection and analysis were conducted according to international principles of maintaining privacy and confidentiality of personal information.With a total of 5,149 EIMCs performed between 2010 and the end of 2014, Swaziland now leads the Eastern and Southern Africa region in the scale-up of EIMC. By mid-2014, 123 health care workers (45 doctors and 78 nurses) had been trained through 11 clinical trainings. Five providers, trained as trainers, facilitated clinical trainings and conducted mentorship visits to newly trained providers. Approximately 80% of the infants were circumcised in the immediate postpartum period before discharge. The remaining approximately 20% of infants were circumcised later, and included referrals from other facilities or in tandem with immunization or routine postpartum visits. Notably, Swaziland’s EIMC program has not reported any moderate or severe adverse events to date at the time of publication of this article. Severe adverse events require extensive intervention with referral or specialist input, mild adverse events require minimal or no intervention, and moderate adverse events can be classified as neither severe nor mild, but do require intervention and are usually managed on-site. Because moderate adverse events are managed on-site, providers may have underreported these adverse events, but this did not emerge as an issue in any focus group discussions or in-depth interviews. In 2015, Swaziland became the first PEPFAR male circumcision priority country to draft a costed operational plan that includes EIMC.80% of circumcisions took place in the immediate postpartum period.In 2015, Swaziland became the first PEPFAR male circumcision priority country to draft a costed operational plan that includes EIMC.In Swaziland, EIMC integration starts during the pre-pregnancy period and continues through the postnatal period . AntenatSwaziland registers approximately 34,249 births per year.In 2011, the MOH developed the “Swaziland Task-Shifting Implementation Framework in Support of Quality Health Service Provision.” According to the framework, some minor procedures were to be shifted from doctors to nurses.According to a representative sample of both doctors and nurses at RFM Hospital, the facility with Swaziland’s most established EIMC program, when doctors and nurses are trained together, doctors feel more comfortable providing nurses the autonomy to lead the program. RFM Hospital started task shifting for EIMC in 2010 because doctors could not meet client demand for the service. Although hesitant in the beginning, hospital management embraced task shifting for EIMC because of the excellent clinical outcomes. The strong safety record to date at the time of publication of this article, as evidenced by the absence of documented severe or moderate adverse events, has further strengthened national confidence in EIMC-trained nurses. Global evidence in support of task shifting for male circumcision, particularly from Kenya, reinforces the argument in its favor.Development partners have primarily supported the procurement and distribution of EIMC instruments, including Mogen clamps, prepackaged EIMC kits, and consumables. Within the next 5 years, the MOH plans to assume responsibility for EIMC supply and equipment procurement within its supply chain systems for the MNCH platform.In 2011, the MOH established the position of National Male Circumcision (MC) Coordinator under the Swaziland National AIDS Program. This position supports both the VMMC and EIMC programs. According to the National MC Coordinator, Swaziland’s MOH viewed the EIMC program as both a way to further its HIV prevention goals and as an opportunity to strengthen MNCH services. EIMC stands to improve health outcomes for mothers and their babies by increasing attention to improving services, including strengthening infection prevention measures, reinforcing close monitoring of newborn health, encouraging routine neonatal physical examinations, discouraging early discharge, and promoting postpartum follow-up for both mothers and babies.Swaziland has not yet completed a formal evaluation of EIMC, but EIMC integration into the MNCH platform appears to have been an effective approach to the delivery of services based on the number of EIMCs conducted as well as the following markers:EIMC indicators were integrated into national monitoring tools including the antenatal care (ANC) register, ANC card, child welfare card, child welfare register, and postnatal register.EIMC has been integrated into the comprehensive package of essential services for healthy baby boys.EIMC is part of the health education content discussed during routine antenatal care visits.EIMC consent forms for parents  are distHealth facility management has identified EIMC focal people.All public health facilities that offer labor and delivery services have allocated space to perform EIMC within their maternity units.Facility doctors oversee the EIMC service delivery as well as facility-level EIMC training activities.In the early stages of VMMC programming in Swaziland, a technical working group led by the MOH with participation from development and implementing partners provided oversight. Under the broad technical working group for VMMC, a subgroup focused on technical aspects of EIMC. This subgroup coordinated various aspects of the EIMC program, including macro-level program planning, clinical skills training, facility identification and assessment, and quality assurance. In February 2011, this technical team developed and piloted EIMC quality assurance supportive supervision tools, as well as a quality assurance implementation plan. As EIMC expanded to additional facilities, program planners recognized that it was critical to fully engage the MNCH platform for an integrated, robust, and sustained EIMC program. Efforts are currently under way to bring the SRHU, which is responsible for the MNCH platform, fully into the coordination framework.It is envisaged that the VMMC technical working group, under the leadership of the National MC Coordinator, will include the manager of the SRHU. EIMC issues will be addressed through ad hoc working groups under the VMMC technical working group.The majority of key informants stressed that the human resource needs of an EIMC program are different from those of the intensive, time-bound, VMMC catch-up program. While EIMC is the long-term sustainability plan for VMMC, it is linked to, but also distinct from, the VMMC program. For adolescent and adult VMMC services, dedicated nurses and doctors were hired to meet the ambitious VMMC catch-up targets. MOH interviewees stated that this approach would be neither practical nor desirable for an integrated, sustainable EIMC program.-To face the human resource challenges for EIMC scale-up, the MOH, in collaboration with its partners, first trained EIMC providers, doctors, midwives, and nurses, through competency-based clinical training beginning in February 2011. Swaziland was the first country to pilot the competency-based clinical skills training in EIMC using the WHO/Jhpiego “Manual for Early Infant Male Circumcision Under Local Anaesthesia” and the associated UNICEF/Jhpiego facilitators guide and learners workbook.With the introduction of EIMC services, MOH stakeholders anticipated concerns about the introduction of an “additional” task without providing additional compensation. This was a particular challenge because doctors and nurses involved in the VMMC program had been compensated for the extra hours worked in support of the program. The MOH also needed to ensure that routine and emergent demands of the MNCH platform were not compromised by the introduction of EIMC in MNCH units. For these reasons, according to representatives from the Swaziland National AIDS Program, the MOH scaled up EIMC slowly. A considered, unhurried scale-up allowed time for facility teams to develop creative and practical solutions to any problems that arose. While the issue of compensation is still a sensitive one, ongoing inclusive dialogue is helpful in clarifying decision-making rationale.A considered, unhurried scale-up allowed sufficient time for facility teams to develop creative and practical solutions to any problems that arose.To address human resource constraints, some higher-volume sites, such as the Mbabane Government Hospital and the RFM Hospital, allocated dedicated, trained midwives to EIMC. Facility management redistributed staff despite human resource shortages and without financial incentives, which demonstrates ownership of the EIMC program at the facility level. Assistance from partner-supported EIMC motivators—to educate clients, link clients to services, and help complete paperwork—also relieved providers of some supportive functions.,Formative research has emphasized that EIMC sensitization efforts must provide parents with the information to make informed decisions.factors and themes that contributed to the development of Swaziland’s fledgling EIMC program:In reviewing EIMC program data and feedback from key stakeholders, several critical program components emerge. Distilled findings across all results areas highlight the presence of the following Program backing from committed MOH leaders who have been termed early adopters in implementing an evidence-based EIMC intervention.Consistent and coordinated funding for EIMC across multiple funding sources during the early stages. UNICEF funded the first EIMC pilot at RFM Hospital in 2009. Since then, PEPFAR has provided consistent funding through USAID-supported EIMC expansion, which has helped the program establish a sound foundation.The role played by RFM Hospital, whose model EIMC pilot encouraged Swaziland to move quickly from EIMC adoption to program implementation. RFM Hospital’s initiative and leadership informed the later roll-out of the EIMC program, highlighting the need for dedicated EIMC staff and space as well as linkages and coordination across the MNCH platform.Targeted technical support from implementing partners. An example of technical assistance that supported program scale-up included formative research, supported by PSI and completed in 2013, that informed EIMC program decision making. This research found that there was a near-universal perception that consent for EIMC cannot be granted by one parent alone, and emphasized that EIMC sensitization efforts must provide parents with the information needed to make informed decisions. Another example of targeted technical support included the efforts of Jhpiego’s Maternal and Child Health Integrated Program to help providers achieve competency through a mix of classroom and clinical mentorship. Other organizations, such as the Elizabeth Glaser Pediatric AIDS Foundation and mothers2mothers, also played pivotal roles in informing potential clients through community and facility education sessions.Formative research that informed decision making. A study of knowledge, attitudes, and practices (KAP) conducted by RFM Hospital helped direct the EIMC pilot and, eventually, national implementation. Later, an MOH-led, PSI-supported KAP study informed community- and facility-based EIMC demand-creation efforts.A policy environment open to task shifting. To overcome the human resource challenge, in 2011 Swaziland’s MOH developed the “Swaziland Task Shifting Implementation Framework in Support of Quality Health Service Provision.” This framework allows nurses to perform minor procedures that were previously conducted only by doctors.challenges, listed by results area:While these components contributed to a growing national program, EIMC stakeholders also stated that scale-up and implementation of EIMC in Swaziland were not without the following Legislation is required to enact task shifting. Although the MOH approved the task shifting framework, fully operationalizing it remains a challenge, as does securing task shifting support from all relevant stakeholders.Early postpartum discharge of the mother/baby pair results in missed opportunities for EIMC. WHO recommends that EIMC should be performed at least 12 hours after birth to ensure that babies are healthy and stable before the procedure. However, due to high birth volumes and limited space, clients are often discharged before 12 hours postpartum, despite global guidance that mothers and babies should remain at facilities for 24 hours after birth, the period of greatest risk.EIMC requires broad coordination across multiple stakeholders at the national level. In Swaziland, because EIMC was conceived within the larger VMMC strategy and coordinated by the Swaziland National AIDS Program, involvement of key stakeholders from the SRHU was not as extensive as desired.Program ownership should be fostered at all levels to avoid the perception of a donor-driven process. Although the EIMC program has been implemented within public health facilities, it still depends on donor support for material and financial resources. Moving forward, Swaziland will need to assume greater financial ownership as donors limit funding for EIMC.Human resource constraints can pose challenges for service continuity. The EIMC program is constrained by regular staff rotations of EIMC-trained providers. EIMC services are further challenged by limited numbers of EIMC-trained providers inhigh-volume facilities and already-limited human resources for health care services.The EIMC program is constrained by staffing shortages as well as regular staff rotations of EIMC-trained staff.The consent process for EIMC is complex. Parents should be ready to make a decision about EIMC by the time they are admitted to facilities for deliveries. Parents and key decision makers should be sensitized before pregnancy or in early pregnancy. Early education allows couples and families the time to make considered decisions about EIMC.Client counseling needs dedicated educators. Especially in the early stages of program implementation and scale-up, dedicated educators can help establish and sustain EIMC services amid the multiple demands of busy and often understaffed MNCH units.EIMC has vocal global and regional opponents. Misinformation can jeopardize fledgling EIMC programs unless these programs continue to involve and educate communities and health care workers.Like PMTCT, EIMC provides an opportunity for nurses to help lead the way toward an HIV-free generation. Because there are approximately 12 times as many registered nurses as doctors in Swaziland, and because an overwhelming number of public sector facilities are led by nurses,As with all VMMC programming, program staff must establish a careful balance between service delivery and community awareness. Informed demand from parents and communities for the service may also support the establishment of EIMC as a service delivery priority. However, for countries with developed VMMC programs that are now introducing EIMC for sustainability, it is also important to recognize that EIMC requires a different approach—standards and guidelines for VMMC must be expanded and adapted to address service provision on a different platform.Swaziland has become the first country to implement EIMC programming quickly in response to the growing evidence supporting the health benefits of the procedure. In a country without a tradition of circumcision, where the sociocultural norms are not favorably predisposed to EIMC, and where VMMC scale-up faced challenges related to client demand, the EIMC program has expanded, which is particularly impressive because of the absence of a targeted national EIMC communication campaign. Continued expansion holds the promise of averting thousands of HIV infections and is a large step toward creating an HIV-free generation in Swaziland.


The rates of metabolic diseases, such as type 2 diabetes mellitus (T2DM), obesity, and cardiovascular disease (CVD), markedly increase with age. In recent years, studies have reported an association between metabolic changes and various pathophysiological mechanisms in the central nervous system (CNS) in patients with metabolic diseases. Oxidative stress and hyperglycemia in metabolic diseases lead to adverse neurophysiological phenomena, including neuronal loss, synaptic dysfunction, and improper insulin signaling, resulting in Parkinson’s disease (PD). In addition, several lines of evidence suggest that alterations of CNS environments by metabolic changes influence the dopamine neuronal loss, eventually affecting the pathogenesis of PD. Thus, we reviewed recent findings relating to degeneration of dopaminergic neurons during metabolic diseases. We highlight the fact that using a metabolic approach to manipulate degeneration of dopaminergic neurons can serve as a therapeutic strategy to attenuate pathology of PD. Changing lifestyles means that many older people suffer from metabolic syndromes, including type 2 diabetes (T2DM), obesity, and cardiovascular disease  showed that feeding behavior is influenced by dopamine levels (Szczypka et al., Improper functioning of dopaminergic neurons in obesity is an important issue (Stice et al., CVD is generally accompanied by hypertension and atherosclerosis due to the accumulation of atheromatous plaques in coronary arteries, and is one of the main causes of death worldwide (Braunwald, Metabolic changes due to aging could affect multiple neuropathological mechanisms, and may also contribute to the progression and onset of PD Figure . InsulinJS wrote the preliminary draft and revised details of the manuscript. JK revised all manuscript in detail.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.


Despite extensive research, institutional policies, and practice guidelines, procedural pain remains undertreated in hospitalized children. Knowledge translation (KT) strategies have been employed to bridge the research to practice gap with varying success. The most effective single or combination of KT strategies has not been found. A multifaceted KT intervention, Evidence-based Practice for Improving Quality (EPIQ), that included tailored KT strategies was effective in improving pain practices and clinical outcomes at the unit level in a prospective comparative cohort study in 32 hospital units (16 EPIQ intervention and 16 Standard Care), in eight pediatric hospitals in Canada.In a study of the 16 EPIQ units  only, the objectives were to: determine the effectiveness of evidence-based KT strategies implemented to achieve unit aims; describe the KT strategies implemented and their influence on pain assessment and management across unit types; and identify facilitators and barriers to their implementation.Data were collected from each EPIQ intervention unit on targeted pain practices and KT strategies implemented, through chart review and a process evaluation checklist, following four intervention cycles over a 15-month period.Following the completion of the four cycle intervention, 78% of 23 targeted pain practice aims across units were achieved within 80% of the stated aims. A statistically significant improvement was found in the proportion of children receiving pain assessment and management, regardless of pre-determined aims (p < 0.001). The median number of KT strategies implemented was 35 and included reminders, educational outreach and materials, and audit and feedback. Units successful in achieving their aims implemented more KT strategies than units that did not. No specific type of single or combination of KT strategies was more effective in improving pain assessment and management outcomes. Tailoring KT strategies to unit context, support from unit leadership, staff engagement, and dedicated time and resources were identified as facilitating effective implementation of the strategies.Further research is required to better understand implementation outcomes, such as feasibility and fidelity, how context influences the effectiveness of multifaceted KT strategies, and the sustainability of improved pain practices and outcomes over time.The online version of this article (doi:10.1186/s13012-014-0120-1) contains supplementary material, which is available to authorized users. Pain assessment and management practices for hospitalized children remain sub-optimal, despite significant research, best practice guidelines, and institutional policies. Knowledge translation (KT) strategies can be effective in promoting health care professionals’ use of clinical research evidence to enhance clinical practice and improve clinical outcomes ; howevere.g., reminders, educational materials, educational outreach, and audit and feedback) in the dissemination of practice guidelines has resulted in small to moderate improvements in patient care . EPI. EPI8]. ysplasia . EPIQ waThe CIHR Team in Children’s Pain successfully implemented the EPIQ intervention in a prospective cohort comparative design study with repeated measures. Thirty-two inpatient hospital units, consisting of medical, surgical, and critical care units from eight Canadian tertiary, pediatric urban-based health centers, participated in the study over a 15-month intervention period. Details regarding the eligibility of participating units have been previously described . Sixteenet al.. Al. Al13]. e.g., physicians, nurses, quality improvement personnel) were identified on each intervention unit to lead and champion EPIQ. The identification of champions and their motivation to participate in the intervention varied from unit to unit; for example, some were recommended by the unit manager, while others volunteered when learning about the intervention. These individuals formed the Research Practice Council. Effort was made to attain multidisciplinary representation. On average, each Research Practice Council included four to six members, with a total of 93 members across the 16 EPIQ units in the eight sites by the end of the study. Over one-half (56%) of the Research Practice Council members were nurses ; 19% were physicians ; and 25% were from other professions .In the Preparation Phase of EPIQ, a small group of multidisciplinary clinical staff members ; increasing the routine use of age appropriate, validated pain assessment measures .All units initially developed one pain practice change aim; 6/16 (38%) focused on improving pain management practices; 9/16 (56%) chose pain assessment, and 1/16 (6%) chose a combination of pain assessment and management. Seven units took on additional practice change(s) in subsequent intervention cycles, with a total of 23 discrete pain practice change aims developed by the final cycle. Two of the initial aims (on two different units) were abandoned (1 pain management aim and 1 combined pain assessment and management) and replaced with more focused aims, which better suited the pain practice needs of the units; 11/23 (48%) of the final aims focused on improving pain assessment and 12/23 (52%) on pain management practices , educational outreach activities , reminders , and audit and feedback . While other potential KT strategies exist, these four types were selected by the research team based on their effectiveness at the time of the study. All interventions used to achieve the practice change aims were evidence-based. Examples of KT strategies included: Educational posters based on Cochrane reviews of pain management interventions , reminders about targeted practices strategically posted on the units or patient charts; laminated validated pain assessment scales placed at the patients’ bedside; educational instruction on the targeted pain practices in orientation sessions for new and returning staff; educational outreach to engage clinicians during reports on patient pain during patient care rounds; and summaries of high impact published articles on pain practices in unit newsletters , using the Rapid Cycle Evaluation Form, developed and pre-tested specifically for this study.Immediately following each of the four EPIQ intervention cycles, data were collected on all of the intervention units. The research nurses and Research Practice Councils completed a Process Evaluation Checklist  for eache.g., mean patient age on unit), and frequencies and percentages for categorical factors . The number of KT strategies implemented by type was summarized using medians given the nature of the data. The frequency and proportion of patients receiving targeted pain practices were summarized by intervention cycle. Logistic regression, using generalized estimating equations , was used to model receipt of targeted pain practice onto cycle time period to determine if differences in the likelihood of receipt of pain practices existed over time. In separate analyses, the Kruskal-Wallis non-parametric test was used to analyze the influence of unit type on the median number of KT strategies used. Linear mixed models accounting for the correlation of multiple strategies within each unit were used to model the usefulness score of strategy on type of strategy.Unit characteristics were described using means and standard deviations for continuous factors . Qualitative data collected on barriers and facilitators to the implementation of KT strategies from the Process Evaluation Checklist . An. An22]. et al.. Th. Th23]. et al.. Ac. Acet alsupport) ,[27].The planning, development, and implementation of multifaceted KT strategies require support from unit leadership, dedicated staff time, and financial resources. In this study, the research nurses assisted pain practice, health care professional champions throughout the process and each unit received a small amount of funding for the development of unique KT strategies. The sustainability of the improved pain practices and the continued use of KT strategies to achieve practice change without the support of the research nurse or study resources are unknown. In a recent casebook on the experiences of the research nurses of the implementation of EPIQ, a number of the strategies used were identified as costly and/or labour intensive to create and maintain .The overall aim of this study was to improve pain assessment and management over time. Multifaceted, tailored KT interventions may be the first step in promoting optimal pain practices; however whether or not they are the answer to sustained improvement is unknown. Research is required to evaluate the effectiveness of KT strategies over time and sustainability of these pain practice changes when more formal research supports, such as research nurses are not available. Additional factors, such as the complex organizational structures in which the majority of clinicians work, institutional policies, and leadership support, can exert significant influence on the success of planned practice changes and require additional evaluation. Further research is also required to evaluate the use of KT strategies in less resource intensive sites, such as community or rural hospital settings, and factors related to the quality and consistency of the implementation process, such as feasibility and fidelity.