Violence against women (VAW) is a major problem worldwide, with one in three women experiencing violence in their lifetime. While interventions to prevent violence (primary prevention) are extremely important, they can take many years. This review focuses on secondary and tertiary prevention interventions that address the needs of survivors of violence and aim to prevent recurrence. This review also focuses on studies taking place in low and low-middle income countries, where rates of VAW are highest.Searches of peer-reviewed and grey literature took place from March–June 2016 through databases  and by consulting experts in the field. Only primary research was eligible for inclusion and studies had to focus on secondary or tertiary prevention for survivors of VAW in low or low-middle income countries. All study designs were eligible, as long as the study examined client-related outcome measures . Data were extracted and quality of the studies was assessed using the Effective Public Health Practice Project Quality Assessment Tool for Quantitative Studies and a qualitative quality assessment tool developed by Mays and Pope. Due to the low number of results and heterogeneity of the study populations and outcomes, a narrative synthesis was conducted and evidence was summarized.One thousand two hundred fifteen studies were identified through the search strategy and 22 of these met the eligibility criteria. Overall, the evidence for interventions is weak and study limitations prevent definitive conclusions on what works. There is some evidence that interventions targeting alcohol use, both among perpetrators and survivors, may be effective at reducing VAW through secondary prevention, and that psychotherapy might be effective for survivors of non-partner sexual violence through tertiary prevention. Finally, some evidence exists for crisis centres increasing survivors’ access to services (through both secondary and tertiary prevention), however, assessment of their impact on future VAW are needed.Though some interventions for survivors of VAW have shown evidence of effectiveness, further research is needed, especially high-quality studies with quantitative outcome data.The online version of this article (doi:10.1186/s12889-017-4502-6) contains supplementary material, which is available to authorized users. Violence against women (VAW) is a major issue worldwide, with an estimated 35% of women, or roughly 1 in 3, experiencing either physical and/or sexual intimate partner violence or non-partner sexual violence in their lifetime . The secWomen experiencing violence face increased preventable morbidity and mortality, making VAW a pressing public health concern. Both forms of VAW can lead to serious short and long-term harm for survivors , 4. PsycPublic health interventions, such as those aimed to address VAW, can be divided into three types: primary, secondary or tertiary prevention Fig.  12, 13], 1312, 1A WHO multi-country study found that in general, VAW is more prevalent in low and middle income countries than in high income countries . LifetimStudies eligible for inclusion were those that focused on secondary or tertiary prevention for female survivors of IPV or non-partner sexual violence, and were conducted in a country defined as low or low-middle income by the World Bank . IncludeSearches were conducted separately for the two major areas of VAW: intimate partner violence (IPV) and non-partner sexual violence. The search strategy involved systematic searches of 8 medical and social science databases between March and June 2016. The following databases were searched for literature on both IPV and non-partner sexual violence: Embase, CINAHL, WHO Global Index Medicus, Medline, PsychINFO, Web of Science, The Cochrane Library, Applied Social Sciences Index and Abstracts (ASSIA) and Sociological Abstracts. A search on IPV only was also performed in one additional database: International Bibliography of the Social Sciences (IBSS). A search for grey literature on non-partner sexual violence was also performed using the databases Opengrey and Greylit, as well as Google and Google Scholar (top 200 results only).The search terms and their combinations Table  were adaFollowing compilation of all articles resulting from this search strategy, 245 abstracts were independently co-screened by LK and ST, with inter-rater reliability of 97.1%, indicating clarity of the inclusion criteria. The seven discrepant ratings were resolved by discussion to reach a consensus, then the remaining articles were screened independently.The quality of included quantitative studies was assessed using the Effective Public Health Practice Project (EPHPP) Quality Assessment Tool for Quantitative Studies (QATQS) . PreviouData were extracted from all quantitative studies on IPV by one reviewer (LK), and all quantitative studies on non-partner sexual violence by another reviewer (ST). The data extraction form was based on recommended data for inclusion from the Cochrane Handbook .The quality of included qualitative studies was assessed using a tool created by Mays and Pope; the specific criteria are outlined in Table Due to the heterogeneity of the studies selected, a meta-analysis of data could not be conducted. Data and information extracted was synthesised in a narrative review.n = 11) of these used mostly quantitative methods and had a total of 2185 participants. The other half of the included studies (n = 11) used mostly qualitative methods , followed by Asia and the Pacific , and only one study (5%) took place in Latin America  focused on intimate partner violence  focused on adult female survivors of VAW (and some teens over 15 were included as “adults”) –36. Two The most commonly studied intervention was psychotherapy or counselling, with 13 studies (59%) examining various forms of this intervention. Two of these studies studied the effects of Cognitive Behavioural Therapy (CBT) , 39, whiThe second most commonly studied intervention was crisis centres, which were the focus of 6 studies 27%), all using mostly qualitative data to study outcomes %, all us, 44, 45.The remaining three studies examined other interventions, including: Family and Sexual Violence Units in police stations, Family Support Centres in hospitals, a counselling and referral hotline for survivors of VAW, a service referral pathway, and family mediation , 26, 46.Four 36%) of the 11 quantitative studies had an overall quality rating of strong, two (18%) were rated moderate, and the remaining five 45%) had a weak quality rating  were mixed-methods evaluations that focused on collecting quantitative process data and qualitative outcome data [The methodological quality appraisal of the 11 qualitative studies did not result in an overall score, but instead an assessment of strengths and weaknesses for each study, which are outlined in Table ome data –29, 44. ome data , 45, 46.Some evidence was found for the effectiveness of psychotherapeutic and counselling interventions when they were designed to reduce alcohol use, both among perpetrators and survivors of VAW. First, a randomised controlled trial conducted in India found that cognitive behavioural therapy (CBT) for men who were being treated for alcohol dependency syndrome (ADS) was effective at reducing violence against their wives in India . Whilst A second randomised controlled trial examined the effectiveness of the WHO’s Brief Intervention for Hazardous and Harmful Drinking for female sex workers in Kenya who reported moderate drinking . The stuFinally, the last study that examined a counselling intervention for alcohol was a cluster-randomised controlled trial conducted in slums in Mumbai, India . IndividSome evidence was also found for psychotherapeutic interventions when they were used as treatment for survivors of non-partner sexual violence. All four studies found were conducted in the Democratic Republic of Congo (DRC). The well-established psychotherapeutic treatments described above , were modified to increase cultural relevance and to allow delivery within the local constraints.First, a cohort study by Bass et al.  evaluateAllon  evaluateSix studies were identified which evaluated the effectiveness of five interventions that utilised counselling or support groups , 42, 43.In contrast to the other counselling interventions, which aimed to reduce psychological trauma, Hogwood et al.  studied A cohort study by Hustache et al.  examinedA study by Lekskes et al.  comparedA study by Deb et al. , examineTwo additional qualitative studies evaluated the effect of counselling interventions for survivors of war-related (mostly non-partner) violence. In Sierra Leone, local female social workers provided one-on-one psychosocial support to women following the war . InterviFive evaluations of Crisis Centres were conducted using the mixed-methods approach outlined previously, consisting mainly of quantitative process data and qualitative outcome data –29, 44. A mixed-methods evaluation of the ISANGE One Stop Centre in a public hospital in Kigali, Rwanda found that the quality of medical and forensic services available to survivors was very high and that linkages with police services were strong . HoweverThe Dilaasa Crisis Centres, located at two public hospitals in Mumbai, India, were found to effectively reach low-income and marginalised survivors . Many suOne-Stop Centres in Kenya and Zambia were categorized by their location and ownership, and those located inside health facilities and owned by hospitals were found to be better set up to achieve a broader range of legal and health outcomes for survivors . SurvivoAn evaluation in Nepal used mobile reproductive health camps to identify survivors of VAW and to provide them with comprehensive crisis centre services . 86% of casas de la mujer (women’s centres) resulted in survivors stating that they had new perceptions of women’s roles in society, increased emotional support and knowledge about their health and legal rights, decreased violence by their partners, and increased involvement in programs to help other survivors.The final evaluation of Crisis Centres used only qualitative methods, interviewing 21 survivors of domestic violence and 15 stakeholders involved in the centres or related projects . This stA study by Human Rights Watch evaluated interventions for VAW in Papua New Guinea (PNG), including: Family and Sexual Violence Units in police stations, Family Support Centres in hospitals, a counselling and referral hotline, and a service referral pathway . ThroughOne study examined the effectiveness of family mediation in the Democratic Republic of Congo (DRC) through in-depth interviews with participants . Family The studies reviewed suggest some interventions that might be effective at reducing future VAW among survivors. As highlighted in the results section, interventions targeting alcohol use, both among perpetrators and survivors, may be effective at reducing VAW and psychotherapy might be effective for survivors of non-partner sexual violence. Some evidence also exists for crisis centres increasing survivors’ access to services, however, evaluations show that careful implementation and assessment of impact on future VAW are needed. Overall, the evidence for all interventions providing secondary and tertiary prevention for survivors of VAW is weak and limitations to this evidence prevent definitive conclusions on what works.Previous research has found that alcohol consumption is associated with an increased risk of all types of interpersonal violence –49. The Similarly, psychotherapeutic interventions, including CBT and EMDR, have been shown by previous randomised controlled trials and a meta-analysis to be highly effective in treating post-rape PTSD . Four stExamination of the six interventions involving counselling or support groups suggests that the experience and training of the counsellor is likely of high importance in improving mental health outcomes of VAW survivors. Neither the support group nor counselling described by Lekskes et al.  utilisedThe studies focusing on crisis centres all used qualitative outcome measures and determined that these interventions often met the needs of survivors including legal, psychosocial and health assistance, but this was highly dependent on implementation and the resources available , 44, 45.Weak evidence was found for other interventions, including special units in police stations and family mediation. The studies evaluating these interventions relied on qualitative outcome data, which reported some positive outcomes but also many challenges , 26, 46.The focus of this review on secondary and tertiary prevention, while useful for determining what services work for survivors of VAW, may have excluded primary prevention interventions that could be applicable to survivors, as well as the general population. For example, a randomised controlled trial that was excluded from this review found that gender dialogue groups and group savings  were effective at reducing IPV, relative to a group savings-only control group . HoweverRecent reviews have examined interventions for women experiencing violence in high income countries. Alcohol management programs for male perpetrators have been shown to result in significant decreases in domestic violence recidivism , 61, conThis review had several limitations. First, the limited search strategy may have resulted in missed relevant articles. This includes a risk of language bias, as the searches were only conducted in English. We also used a restrictive search strategy in this review to identify studies of high relevance and minimise the number of unrelated results , which again could have led to missed relevant studies. However, many of the articles recommended by experts in the field were identified in the process of database searching, suggesting that most relevant articles were captured. An additional limitation is that data extraction was performed by only one reviewer for several studies (JLW), due to time limitations. However, the use of standardized categories for data extraction and assessment of study quality by multiple reviewers (with high inter-rater reliability), suggests that this was unlikely to cause any problems. Whist this review did have several possible limitations, we attempted to minimise their impact and to mitigate their occurrence. The review methods were developed based on previous reviews in the area –64 and aThis systematic review highlights the limited evidence that exists for secondary and tertiary prevention interventions for VAW in low and low-middle income countries. Though some interventions show promise, further research in this area is essential. In particular, more high-quality, outcome-focused studies are needed to determine which interventions work, and for which populations. For example, while we have some qualitative evidence that survivors were able to access services through crisis centres, further study is needed to know to what degree these services lead to positive outcomes for these survivors, and whether they are more effective for certain survivors, so promotion and outreach can be better targeted. This systematic review has highlighted other key areas for future research as well, including continued study of the effectiveness of alcohol-related interventions for both perpetrators and survivors, and psychotherapeutic interventions for survivors of non-partner sexual violence. Better understanding of the effectiveness of these interventions in low and low-middle income countries will help to prioritize programs and policies that reduce the violence, trauma and suffering that many survivors of VAW face around the world.


Financial supervision means that monetary authorities have the power to supervise and manage financial institutions according to laws. Monetary authorities have this power because of the requirements of improving financial services, protecting the rights of depositors, adapting to industrial development, ensuring financial fair trade, and maintaining stable financial order. To establish evaluation criteria for bank supervision in China, this study integrated fuzzy theory and the decision making trial and evaluation laboratory (DEMATEL) and proposes a fuzzy-DEMATEL model. First, fuzzy theory was applied to examine bank supervision criteria and analyze fuzzy semantics. Second, the fuzzy-DEMATEL model was used to calculate the degree to which financial supervision criteria mutually influenced one another and their causal relationship. Finally, an evaluation criteria model for evaluating bank and financial supervision was established. Financial supervision entails that a specialized agency established by the financial management authority of a country, based on a specific working procedure, uses economic and administrative measures to supervise the financial practices of various financial institutions and to ensure the authenticity, legality, and economic efficiency of financial activities occurring in various financial institutions –2.Calvo and Mendoza  indicateFinancial supervision means that monetary authorities have the power to supervise and manage financial institutions according to laws. Monetary authorities have this power because of the requirements of improving financial services, protecting the rights of depositors, adapting to industrial development, ensuring financial fair trade, and maintaining stable financial order. Hu  indicateBecause of financial liberalization and globalization, innovative financial activities have become prevalent, banking operations have become complex, and financial risks have increased. To manage the rapid change of financial environments effectively, all major countries endeavor to promote financial reform, review financial supervision systems and related laws and regulations, improve financial supervision methods, urge banks to enhance risk management and corporate governance, ameliorate financial systems, and enhance financial competitiveness.Most studies investigating banking supervision indicators have assumed that the evaluation criteria are independent of each other, implying that they do not mutually influence one another and are not causally related. This assumption has limited research on banking supervision indicators. The decision-making trial and evaluation laboratory (DEMATEL) model could be used to transform a complex system into one with well-structured causal relationships by simplifying the relationships between criteria in the system into cause–effect relationships. By quantifying the interrelationships among criteria, we identified the core problems of the complex system and determined how to improve the system.To establish evaluation criteria for bank supervision in China, this study integrated fuzzy theory and the decision making trial and evaluation laboratory (DEMATEL) and proposes a fuzzy-DEMATEL model. First, fuzzy theory was applied to examine bank supervision criteria and analyze fuzzy semantics. Second, the fuzzy-DEMATEL model was used to calculate the degree to which financial supervision criteria mutually influenced one another and their causal relationship. Finally, an evaluation criteria model for evaluating bank and financial supervision was established.Currently, four financial supervision approaches have been adopted internationally, namely the institutional, functional, integrated, and twin peaks approaches –10. Thes1Institutional approachIn this approach, financial institutions are supervised and managed according to their categories . A regulator for a financial institution defines the scope of services that the financial institution can provide and supervises the financial institution from the perspective of security. China, Mexico, and Hong Kong adopt this approach.2Functional approachIn the functional approach, financial institutions are supervised and regulated according to their business type. Each business type is supervised by an independent regulatory authority. By using a purely functional approach, if a financial institution undertakes various types of business , then the financial institution would be supervised and regulated by various financial regulatory authorities. Each regulatory authority regulates and manages one type of business and considers financial security matters for the specific type of business. Italy and France adopt this approach.3Integrated approachIn the integrated approach, a single competent authority is responsible for regulating the financial sector and supervising financial security. This approach has been receiving increasing attention in recent decades because numerous financial institutions have provided comprehensive financial services and their financial businesses cannot be categorized simply according to their operation functions. Therefore, an integrated regulatory authority is required. This model is also called the financial services authority (FSA) model. The FSA in the United Kingdom is representative of the FSA model. In addition, Germany and Taiwan adopt the integrated approach.4Twin peaks approachThe twin peaks approach is based on the concept of regulation by objective. This approach distinguishes two regulatory functions: regulating financial businesses and supervising financial security. In other words, business practices and system stability require separate and independent regulatory authorities . Accordingly, by using this approach, retail-type and wholesale-type financial businesses are required to meet different regulatory standards. Australia and the Netherlands adopt this approach.In 1979, the US Federal Financial Institution Examination Council announced a Uniform Financial Institutions Rating System and recommended that various financial supervisory authorities adopt the CAMELS rating system  [In 2003, the FSA in the United Kingdom began promoting a new evaluation system for bank risks. The risk evaluation model comprises four business risk groups  and six control risk groups  [To respond to the rapid change of international financial situations, the governments of various countries effectively adjusted their supervision policies and considered the examination of financial supervisory authorities and financial early-warning systems extremely crucial. In September 1997, the Basel Committee on Banking Supervision for the Bank for International Settlements announced the Core Principles for Effective Banking Supervision to provide financial supervisory authorities in various countries with evaluation criteria for evaluating the quality of financial supervisory systems. In addition, after the global financial crisis in December 2010, the Basel Committee on Banking Supervision, announced a New Basel Capital Accord (Basel III), which has been a major reform in international banking supervision in recent years and served as a direction for formulating effective supervision practices .The development of financial reform and banking supervision in China can be divided into five phases –13:1Market-oriented planned economic period (1979–1983)During this period, banking practices included deposits, loans, and monetary transfers and did not require assessing credit or operational risks. The governmental supervisory system focused on policy and administrative management without stipulating supervision regulations and operations such as those stipulated for a market economic system.2Period for financial institution legalization and foreign exchange adjustment (1984–1992)The Industrial and Commercial Bank of China was founded in 1984 and undertook industrial and commercial credit business originally operated by the People’s Bank of China. Subsequently, the Industrial and Commercial Bank of China, China Construction Bank, Agricultural Bank of China, and Bank of China became four major state-owned banks and were responsible for industrial and commercial credit businesses, urban construction financing, agricultural financing, and foreign currency exchange, respectively.3First-time macro-control and active internationalization (1993–2001)First-time macro-control occurred and financial supervision according to business type was established. In addition, foreign banks were permitted to operate.4Joining the World Trade Organization and establishing the China Banking Regulatory Commission (2002–2006)The period of 2001 to 2006 during which China joined the World Trade Organization (WTO) was a transition phase for banking supervision in China. The open-door policies during this period were to implement liberalization measures based on WTO commitments fulfillment and the requirements of China’s reform and development.In March 2003, the China Banking Regulatory Commission (CBRC) was founded and belonged to the State Council of the People’s Republic of China. The CBRC was responsible for integrating the People’s Bank of China with other banks, asset management companies, trust and investment companies, deposit-taking financial institutions, and the Central Financial Work Commission.The responsibilities of the CBRC were to formulate related policies and regulations for banking supervision, to be responsible for market access and supervision operation, and to investigate and punish violations. The CBRC, the Securities and Futures Commission, and China Insurance Regulatory Commission supervised and regulated the banking, securities, and insurance sectors, respectively. Accordingly, a financial operation model for financial management and supervision based on business type was established in China –13.5Corporate orientation and financial globalization (after 2006)In 2006, the Regulations on the Administration of Foreign-funded Banks of the People’s Republic of China were announced. Although foreign-funded banks were permitted to establish branches, subsidiary banks received more preferential treatment compared with bank branches pertaining to capital, review processes, business locations, currency type, business items, and target customers.Although China currently performs supervision based on business type, various financial supervisory authorities have gradually established a joint supervision mechanism and exchanged supervisory information through a joint-meeting supervisory mechanism and a regular contact mechanism –13. The The study was reviewed and approved by an institutional review board Zhongshan Institute, University of Electronic Science and Technology of China (ethics committee).Previous studies on financial supervision criteria have a major shortcoming. Most studies have assumed that evaluation criteria are independent of one another and that no causal relationship exists among evaluation criteria. This assumption limited research on financial supervision criteria.To establish evaluation criteria for banking supervision in China, this study integrated fuzzy theory and the DEMATEL and proposes a fuzzy-DEMATEL model. First, fuzzy theory was applied to examine banking supervision criteria and analyze fuzzy semantics. Second, the fuzzy-DEMATEL model was used to calculate the degree to which financial supervision criteria mutually influenced one another and their causal relationship. Finally, an evaluation criteria model for evaluating banking and financial supervision was established.Following the discussed studies on how supervision agencies in various countries supervise banks and those on the criteria for evaluating banking supervision –17, we eThis set of criteria included four dimensions  and 10 evaluation criteria, as shown in The DEMATEL was developed by the Battelle Memorial Institute at the Geneva Research Center. Gabus and Fontela –21 attemIn recent years, the DEMATEL has been employed to solve various problems in various fields. Tzeng et al.  used theZadeh  proposedAccording to fuzzy logic, each numerical value between 0 and 1 is partially correct. In a crisp set, the value of an element is either 1 or 0. Therefore, fuzzy logic can manage fuzzy and indefinite mathematical judgment . TrianguIn this study, regarding the defuzzification procedure and solution derivation, the minimal and maximal fuzzy numbers were used to determine the right and left critical values. The total integral value was determined based on the weighted average of the membership function . The impStep 1: Standardizationaj, j = 1, …, JCalculate all solutions: j = 1, …, J.Step 2: Calculate the left and right normalized critical values, j = 1, …, J.Step 3: Calculate all normalized crisp values, j = 1, …, J.Step 4: Calculate crisp values, The fuzzy-DEMATEL model is an integration of fuzzy semantics and the DEMATEL method. In other words, by applying the DEMATEL method to a fuzzy situation, a causal relationship between variables can be examined in the fuzzy situation and how variables mutually influence one another can be clarified. The computation procedure for the fuzzy-DEMATEL model is elaborated as follows:Step 1: Develop evaluation criteria and design a fuzzy semantic scale.Instead of a conventional scale, a fuzzy semantic scale was used to solve fuzzy problems related to human thinking. In this study, according to Li and Tzeng (2009), triangular fuzzy numbers were used to determine the degree to which variables mutually influenced one another ;  and 10 evaluation criteria .DEMATEL questionnaires were distributed between August 1 and August 10, 2014. For each question, a 5-point scale (4–0) is used to indicate level of influence of each criterion. The scale anchors are in the descending order of very high influence (VH), high influence (H), low influence (L), very low influence (VL), and no influence (No). In this study, a group of Chinese experts provided their viewpoints regarding evaluation criteria for banking supervision in China. The questionnaires were distributed to 12 experts . The author visited each expert in person, explained the content of the questionnaire, and requested each expert to complete the questionnaire. Overall, 12 questionnaires were distributed and returned. The valid return rate was 100%.In this study, 12 experts were invited to provide expert opinions on supervision criteria. Based on the questionnaire results, the causal relationship between criteria and the degree to which criteria mutually influenced one another were calculated. This study used Matlab software to calculate.The fuzzy scale in Xl, Xm, Xn) and then the matrices were normalized. The fuzzy matrices for a direct relationship  were derived based on the column vector u (l ≤ m ≤ u) and the maximal value in u.Subsequently, Eqs –8) were were8) wXl, Xm and Xn for a complete relationship were integrated and (D + R) and (D—R) were calculated, as shown in By using Eq , the matdef and relation ((D - R)def were then calculated, as shown in Finally, Eqs –9) were were9) wdef as the horizontal axis and (D-R)def as the vertical axis, 10 criteria were plotted, as shown in By using (D + R)Based on relation (D - R) and prominence (D + R), a detailed discussion of the 10 criteria and their causal relationship and mutual influence, as shown in High relation and high prominence: Capital adequacy (a1), supervising the board of directors and management level (b1), and credit risk management (d1) appeared in this quadrant. These three attributes were in the category of causes and were the core items that influenced other attributes. The three attributes were key factors for solving problems.High relation and low prominence: Only asset quality (a2) appeared in this quadrant. This attribute influenced other attributes to a low degree.Low relation and high prominence: Soundness of operation control (c1) and consumer complaints handling (c2) appeared in this quadrant. These two attributes were in the category of effects and were influenced by other attributes. The two attributes could not be directly improved.Low relation and low prominence: Earnings (a3), status of complying with major laws (b2), market risk management, and operational risk management (d3) appeared in this quadrant. These four attributes were influenced by other attributes to an exceedingly low degree, suggesting that these attributes were relatively independent.Regarding the degree of influence and causal relationship, we determined that capital adequacy (a1), supervising the board of directors and management level (b1), and credit risk management (d1) were three crucial and core attributes that influenced other attributes and were the key factors for solving problems. According to practical experiences in financial supervision, capital adequacy (a1) is the basis for the equity capital and liquidity of a bank and is the most crucial factor influencing a bank’s constitution. If a bank has high equity capital, then the bank would have a low risk of closure. In addition, supervising the board of directors and management level (b1) is crucial for banking supervision. The fraud processes of a bank typically involve the board of directors and management level for the bank, and therefore, all competent authorities for financial institutions rigorously supervise the board of directors and management level for banks. Moreover, credit risk management (d1) is a crucial criterion for financial supervision. A bank’s credit risk should remain within a safe range to avoid a credit crisis for the bank. By enhancing the performance of the aforementioned three criteria, the performance of other criteria for banking supervision can be improved.Financial supervision means that monetary authorities have the power to supervise and manage financial institutions according to laws. Monetary authorities have this power because of the requirements of improving financial services, protecting the rights of depositors, adapting to industrial development, ensuring financial fair trade, and maintaining stable financial order. The passive function of financial supervision is to improve the operation of financial services and to maintain a stable financial order. The positive function is to protect the rights of depositors and ensure fair trade for financial systems according to financial environments.Previous studies on financial supervision criteria have a major shortcoming. Most studies have assumed that evaluation criteria are independent of one another and that no causal relationship exists between evaluation criteria. This assumption limited research on financial supervision criteria. To establish evaluation criteria for banking supervision in China, this study integrated fuzzy theory and the DEMATEL and proposes a fuzzy-DEMATEL model. First, fuzzy theory was applied to examine banking supervision criteria and analyze fuzzy semantics. Second, the fuzzy-DEMATEL model was used to calculate the degree to which financial supervision criteria mutually influenced one another and their causal relationship. Finally, an evaluation criteria model for evaluating banking and financial supervision was established.This study determined that capital adequacy (a1), supervising the board of directors and management level (b1), and credit risk management (d1) were three crucial and core attributes that influenced other attributes and were the key factors for solving problems. By enhancing the performance of the three financial supervisory criteria, the performance of other criteria for banking supervision can be improved.The fuzzy-DEMATEL model can be used to determine the causal relationships among criteria and the influence of the criteria; to structure complex problems; and to identify, clarify, and improve problems. However, the mathematical model and computation procedures are complex; accordingly, users must pay special attention. In addition, we suggest that future studies adopt other evaluation methods to perform integrative analyses and compare the strengths and weaknesses of various methods.S1 File(DOCX)Click here for additional data file.S2 File(DOCX)Click here for additional data file.


Breast cancer (BC) has been described as the leading cause of cancer deaths among women especially in the developing world including sub Saharan Africa (SSA). Delayed presentation and late diagnosis at health facilities are parts of the contributing factors of high BC mortality in Africa. This review aimed to appraise the contributing factors to delayed breast cancer presentation and diagnosis among SSA women.Five databases encompassing medical and social sciences were systematically searched using predefined search terms linked with breast cancer presentation and diagnosis and sub Saharan Africa. Reference lists of relevant papers were also hand searched. Quality of quantitative and qualitative articles were assessed using the National Institute of Health (NIH) Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies and the Critical Appraisal Skills Programme (CASP) quality appraisal checklist. Thematic analysis was used to synthesize the qualitative studies to integrate findings.Fourteen (14) quantitative studies, two (2) qualitative studies and one (1) mixed method study merited inclusion for analysis. This review identified low knowledge of breast cancer among SSA women. This review also found lack of awareness of early detection treatment, poor perception of BC, socio-cultural factors such as belief, traditions and fear as factors impacting African women’s health seeking behavior in relation to breast cancer.Improving African women’s knowledge and understanding will improve behaviors related to breast cancer and facilitate early presentation and detection and enhance proper management and treatment of breast cancer. Incidence and mortality rates for cancer has increased over the second half of the 20th century and are likely to continue to surge substantially according to World Health Organization (WHO) projections . In 2012Variation in incidence rates may largely stem from greater availability of early detection measures as well as health seeking behaviors of women in developed countries . MoreoveStudies undertaken in Africa suggest low knowledge of breast and cervical cancer awareness –12. ThisThe disparity in BC outcomes in women living in developing and developed countries provides the momentum for this paper to review research on barriers to early presentation and diagnosis of BC in women from Africa. This review is also relevant as barriers may not be limited to early presentation for BC alone. Findings from this review can potentially aid in drafting measures to improve the knowledge and health seeking behaviors of African women. This review was conducted with the aim to synthesize research evidences on the barriers to early presentation and diagnosis of breast cancer among women in sub-Saharan Africa.A comprehensive search strategy was developed to find published studies on BC knowledge and health seeking behaviors of women in sub Saharan Africa. The sub Saharan region was classified based on the United Nations classification of countries . The seaStudies that were included in this review were of any design  published in English language peer-reviewed journals, and primary research articles, that identified barriers to early presentation and diagnosis of BC in women of African descent living in Africa. This included studies that explored knowledge of BC, studies of attitudes or barriers to breast screening, studies that explored attitude to and undertaking of breast self-examination (BSE). Studies that explored health seeking behaviors regarding BC, factors affecting women’s return for follow-up following abnormal test results, diagnostic delays due to service-related factors after suspicious findings by health professionals and studies of African women and women from other ethnic groups, but reported on findings for the included ethnic groups separately were also included.Excluded articles consisted of those that included African women and women from other ethnic groups within the overall sample, but did not report on findings for the included ethnic groups separately. Studies that reported research carried out in Western countries, only reported differences in time to presentation/diagnosis by race and did not explore factors accounting for these differences, only described interventions in relation to increasing uptake of cancer screening and/or improving early presentation/detection rates were also excluded. African women’s perceptions of cancer without information on early presentation and diagnosis were excluded.Data were extracted systematically from all eligible papers through the use of standardized Data Extraction Forms (DEFs) developed by a research team . Two staThe quality of the quantitative studies was assess based on National Institute of Health (NIH) Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies . QualitaFindings from qualitative and quantitative articles were integrated into themes. Thematic synthesis of the qualitative studies  providesThe flow of information through the various stages of the review is represented in Nine (9) of the quantitative articles were descriptive cross-sectional surveys , 40, 42 A total of 6681participants were recruited and involved in the14 included quantitative studies. The least number of participants in a study was 110 women  and the Several barriers to early presentation and diagnosis of BC were reported across all studies. Majority of the studies (15) reported lower participants’ knowledge of the causes, symptoms, early detection and treatment of BC , 40–42. Awareness of BSE and CBE were reportedly very low in some studies ,35,42,41Some studies showed that participants with higher educational attainment were more knowledgeable about BC issues than those with lower levels of education and or had no formal education ,33. WomeThe sources of respondent’s information on BC were investigated in some studies ,34,42,41it kills fast’. In some studies, participants were reported to have the view that, African women were not susceptible to BC. About 55% believed it affected Caucasians only [“We normally know that if someone gets cancer they will end up dying” [“My understanding of cancer is that it is like a blue gum tree, you cut it, a new growth begins to sprout from the trunk, so when the breast is removed, new cancer begins again and spreads to other parts of the body”. “In fact, AIDS is much better than breast cancer,” another asserted, “because at least you can manage it with drugs, you don’t develop maggots like cancer. So I say anything that has no medicine is not good.” [Varied perceptions of BC were also reported across studies. A large number of participants perceived BC as very serious form of cancer ,34 or deans only ,35. Otheans only ,35. Resuans only ,30,32. It good.” . In somet good.”  whereas The review revealed poor health seeking behaviors among women in SSA and this influence the early presentation and diagnosis of breast cancer. Poor health seeking behaviors were as a result of socio-cultural factors, fear of being diagnosed cancer and death from cancer, as well as traditional practices, A study, , revealeFear was reported as a contributing factor for women’s failure to seek treatment for BC ,37,39,42The fear, stigma and cost involved in diagnosis and treatment in Africa compels women to seek for alternative source of BC care including traditional healer and or herbalist. Pace et al.,  reportedOkobia et al,  also repSocio-demographic characteristics such as age, marital status, women education and type of residence was reported as impediments to BC treatment. Age as a barrier to late presentation was described by ,33,39. MBarriers owing to inadequate screening programs, attitude of health personnel’s and access to healthcare were also intimated to contribute to late presentation of BC. Difficulty in accessing healthcare as a result of living in a remote area and the lack of seriousness of health professionals about BC was shown to be a barrier to early presentation . Maree aAuthors rated majority of the studies to be of good or high quality based on our assessment criteria –38,40–42This review sought to identify health seeking behaviors and other contributing factors to delays in BC detection among African women. We identified knowledge gap as an important contributing factor for late presentation and early detection measures. Knowledge is an important determinant of healthcare utilization and this association has been previously established. Studies also reveal that this barrier to BC treatment and management is not only evident among African women but also in other developed countries including UK, USA, Canada, Hong Kong and India where an association between poor knowledge and health literacy with late detection of BC and case presentations persist –48.In some African countries discrepancies exist between the knowledge of participants in urban and rural settings. Whereas urban middle-income women identified lifestyle factors such as stress, sedentary behaviour, and dietary factors as possible risk factors for BC, rural women indicated, remnants of milk retained in the breast, keeping money or a mobile telephone inside their braziers, witchcraft, evil spirits and punishment from the gods as factors contributing to BC ,35. The There is evidence from this review that women in Africa have a low level of knowledge on early detection measures for BC, which appears to affect their practices and involvement. The combined effect of poor knowledge of early detection measures and low health literacy has been identified as influencing the disease in some developed countries ,33,48. AWhat is of much concern in sub Saharan Africa is the availability of accurate health information. Sources of information determines how accurate the information is, and these information shapes their perception and beliefs about breast cancer, its causes and the need to participate in screening and other important preventive practices. A study undertaken among urban residents in Chicago , reporteStudies reported that, most women received BC information mainly from television (31%), clinics (31%) and health professionals (21%) ,34. OtheThis prompt the need for educational campaigns among African women to enhance their knowledge of BC and benefits of early detection and treatment. The Breast Health Global Initiative (BHGI)  strives Decision to seek medical attention was found to be a barrier to early BC diagnosis and presentation in this review. This is shaped by the women’s preferences for alternative treatment. A study reported that only 29% indicated their preparedness to seek medical attention upon identifying such signs and symptoms whereas others prefer traditional treatment (46%) for BC care ,31,32. WSociocultural factors such as influence of husbands and partners were also important in determining early detection and treatment. The influence of societal factors on access to healthcare is also mediated through their opportunities to education, income, occupation, control over earnings and participation in decision-making. Gender norms and values of women in society determine their status within the household and the community at large, and influence their access to healthcare . In the Access difficulties, long distances and residing in remote areas pose difficulties for women with respect to access to BC diagnosis and treatment. Living in rural areas is associated with greater distances and high cost of transport to access healthcare services ,59. In sThe strength of this review reflects the various themes identified and their consistency with studies from other developed countries on the subject area ,53,62,63Generally, knowledge inadequacy of BC and its early detection measures continue to be one of the most important factors in determining women’s attitude towards BC screening and treatment. Understanding the benefits of early detection and presentation of BC among women was poor across all studies. Sources of information, knowledge of early detection measures, sociocultural beliefs and traditions revealed women’s perceptions of BC. Societal traditions and beliefs play an important role in women’s BC perceptions, screening measures and treatment. The findings of this study prompt educational campaigns among African women to enhance their knowledge of BC, benefits of early detection and treatment.S1 Appendix(DOCX)Click here for additional data file.


Focusing on healthcare referral processes for children with severe acute malnutrition (SAM) in South Africa, this paper discusses the comprehensiveness of documents  that guide the country’s SAM healthcare. This research is relevant because South African studies on SAM mostly examine the implementation of WHO guidelines in hospitals, making their technical relevance to the country’s lower level and referral healthcare system under-explored.n = 5). Combining both methods enabled us to examine the comprehensiveness of the documents as related to guiding SAM healthcare within the country’s referral system as well as the credibility (rigour and stakeholder representation) of the guideline documents’ development process.To add to both literature and methods for studying SAM healthcare, we critically appraised four child healthcare guidelines  and conducted complementary expert interviews (None of the guidelines appraised covered all steps of SAM referrals; however, each addressed certain steps thoroughly, apart from transit care. Our study also revealed that national documents were mostly modelled after WHO guidelines but were not explicitly adapted to local context. Furthermore, we found most guidelines’ formulation processes to be unclear and stakeholder involvement in the process to be minimal.In adapting guidelines for management of SAM in South Africa, it is important that local context applicability is taken into consideration. In doing this, wider stakeholder involvement is essential; this is important because factors that affect SAM management go beyond in-hospital care. Community, civil society, medical and administrative involvement during guideline formulation processes will enhance acceptability and adherence to the guidelines. Malnutrition accounts for 50% to 60% of hospital child deaths in sub-Saharan Africa . Out of As noted by South Africa’s national department of health , the refThis paper aims to understand the complexity of guidelines for care and referral processes of SAM in South Africa. Specifically, we (1) identified guidelines related to SAM care and referral processes ; (2) examined the quality of guidelines that are used in South Africa and (3) discussed the implications of the strengths and shortfalls of the documents reviewed.Healthcare is best performed with the use of policy guidelines or protocols. Waterlow  found thSouth Africa-based studies that have previously explored SAM treatment guidelines have only focused on adaptation of WHO-Steps for in-patient care of children with SAM to rural hospitals. Such studies acknowledge the feasibility of implementing WHO-Steps of managing SAM in rural hospital settings. However, omission of some procedures (i.e. feeding per every 3 hours at night and giving routine antibiotics) by health workers was a hindrance to the guidelines’ full implementation , 14. To Also neglected in studies that explore guidelines on SAM healthcare is the assessment of whether the documents are clear on practice, up to date (with revision plan) and if they were developed rigorously, by whom and under whose influence. In a study meant to appraise WHO guidelines for maternal health, Polus et al.  acknowleSouth Africa did not have a national framework for managing malnutrition until 2012; prior to that, four of nine provinces adopted the WHO-Steps guidelines. The rest of the provinces utilised IMCI and South Africa’s standard treatment guidelines and essential drugs list for hospital level paediatrics, which were not explicitly explored in the context of SAM . By focuThis study is a critical appraisal of care guidelines for SAM care that inform the referral process in South Africa. Table Critical appraisal of the documents involved guidelines that address the care and referral of children with SAM. Through the consolidation of subject matter according to expert recommendations  and internet searches (google and government websites), we identified four guidelines  that are used  in South Africa (Box 1).Box 1 List of guidelinesHealthcare guidelines are reviewed and assessed using various tools that reveal their complexity and technical quality . We utilThe WHO framework examines five components, namely initiating facility, referral practicalities, receiving facility, supervision and capacity-building . In specComprehensiveness of the referral steps was mainly examined using three of the six domains . These domains are specific to the SAM referral process, while the remaining three assess the rigour of guideline development processes Fig. .The guidelines (n = 4) were appraised by three individuals , with two authors (FNM-C and EE) individually appraising all documents using an online portal and a further three individuals  appraising one document each using hard copies. Responses were scored on a scale of 1 (strongly disagree) to 7 (strongly agree) on each of the AGREE tool domains.To describe the referral representation and complement AGREE, five in-depth interviews were conducted with two academics, two frontline health workers  and a government official involved in guideline development. One government official, one academic and one frontline health worker commented on the EDL, a second health worker commented on the IMCI, while a third academic mainly commented on the IMC-SAM and added comments to other guidelines. The interviews explored the clarity of referral steps contained in the guidelines, adherence to the AGREE criteria and whether they could be recommended for use in various levels of SAM referral. Specifically, we sought information on stakeholder involvement, rigour of development (including use of evidence) and editorial independence .The lead researcher tabulated raw scores from all appraisers and emailed them for crosschecking and reconsideration before aggregation. The AGREE online portal scaled the percentage from all appraisers; in addition, we used the AGREE consortium (Box 2) formula to incorporate off-line appraisals.Box 2 AGREE’s scaled domain score formulaeMaximum possible score was a sum of all scores of the individual item by scaling the total as a percentage of the maximum possible score for that domainCo-authors (JE and PD) were responsible for ensuring all appraisals were equally incorporated in the final commentary of the SAM documents relevance in SAM referral. To ensure representation of the assessors’ input, the preliminary findings from the critical appraisal were mailed to all participants for member checking .This section is composed of results from the guideline document versus SAM referral steps assessment, AGREE appraisals and expert interviews. The results are outlined for each document  with an overall summary of the documents’ comprehensiveness. We report the guideline documents’ results in order of the oldest to the latest.WHO-Steps aims to improve global inpatient treatment of severe malnutrition in 10 steps. It is expected to address the SAM care problems alongside a WHO manual for managing SAM and the WHO/UNICEF strategy of IMCI. In South Africa, the 10 steps are embedded in two national guidelines (in this study: EDL and IMC-SAM) for hospital use only.The guideline thoroughly elaborates in-hospital diagnosis/care and rehabilitation processes by emphasising appropriate case management and follow-up care . The guiThe guideline scored high on scope and purpose (89%), clarity (75%) and applicability (61%), and lower on stakeholder involvement (44%), rigour of development (27%) and editorial independence (17%).Scope and purpose: the objectives and populations were clearly articulated. It is meant to provide practical help to persons responsible for medical and dietary management of SAM children. Despite its overall clarity, the guidelines’ objectives and problem statements were not easily traceable by section titles.Stakeholder involvement: a 44% score acknowledges that only a few experts contributed to the guidelines. Relevant professional groups or the public were not mentioned as being involved in reducing the stakeholder involvement strength. The specific users of guidelines were not stated, but rather spaces for implementation were identified as hospitals, therapeutic feeding centres, emergency situations and in nutrition rehabilitation centres [ centres . It is uRigour of development: the procedures for updating the guideline and using evidence were not reported. Consideration of benefits, side effects and risks of recommendations were not fully discussed, but case–control-based recommendations, also in the 2013 update of malnutrition care, point to the use of research evidence. Additionally, WHO is known for use of systematic reviews and randomised trials [d trials .Clarity of presentation: recommendations were easily identifiable by having a similar flow per step of care, containing various options of case management. Each step of SAM care started with conditions to note, how to treat, monitoring points, what to prevent and a reference for specific dosage and measures. However, WHO-Steps did not have in-text charts to guide diagnosis, classification of severity and treatment.Applicability: it was made flexible for global dissemination, thus giving room to adaptation to nutritious ingredients and drug options that can be accessed in various contexts. However, the guideline was not thorough on facilitators or barriers of its application and, therefore, implications for resource-limited settings were unknown. Hence, applicability to context-specific conditions could not be guaranteed. It should be noted that the 10 steps have been updated per current evidence; thus the revised version and South Africa’s adapted version are respectively found in the 2013 WHO updates on SAM management and the 2015 South Africa’s operational guidelines for managing acute malnutrition [utrition .Editorial independence: the influence of funding bodies and competing interests on guideline development and/or group members were barely traceable. While disclosure of funders was disclosed, competing interests were unreported and thus unknown.The EDL is a clinicians’ guide for quality, equitable and efficient healthcare in order to save the lives of babies and children . It is mEDL contains a comprehensive medicine list covering in-hospital level SAM diagnosis and treatment, decision to refer back and rehabilitation. However, the role of community health workers during rehabilitation was vague despite their importance in South Africa’s PHC strengthening.The guideline’s highest score were in scope (96%) and clarity (93%), followed by stakeholder involvement (63%), applicability (53%), rigour of development (44%) and editorial independence (9%). Table Scope and purpose: EDL had a clear objective “to reduce child mortality through offering quality healthcare”, emphasising essential medicines, clearly identified target population (children) and maintained consistency with South Africa’s PHC guidelines [idelines . HoweverStakeholder involvement: based on acknowledgements, various teams were involved in EDL development. Singled out were various paediatric and national departments of health, including HIV/AIDS and child health clusters and, in particular, IMCI, tuberculosis and nutrition directories [ectories . DespiteRigour of development: the methods of formulating recommendations and involving external reviewers and other health professions through emails were reported. However, there was no reporting of evidence search, selection and quality. The development process was mostly expert-based with use of some systematically searched evidence (quote 2d). Even where other experts contributed, inclusion of their inputs into the guidelines could not be guaranteed (quote 2e). Despite this, the guidelines had an updating procedure every 3 years, but its pace was slow since the current version is the third since 1998.Clarity of presentation: its structure was clear with the segregation of diseases by chapters. The SAM chapter had headings for each treatment step sub-divided into prevention, detection, treatment and warnings. Different medication options were available; however, continuous reference to other chapters seemed unfriendly for a new user (quote 2f). Despite the shortfalls, key recommendations were easily identifiable and unambiguous.Applicability: barriers and potential resource implications during implementation were not reported. One of the implementation barriers lay in accessing a mineral-vitamin mix ingredient for preparing the F75 and F100 feeds for stabilisation and catch-up (quote 4d under IMC-SAM). Nevertheless, a government official implied resource implications were taken into consideration (quote 2 g). EDL also had useful support tools, including feed recipes, tables and growth charts in appendices.Editorial independence: the roles of EDL funders (the government) were not disclosed. Funding suppliers, such as pharmaceutical companies, were avoided (quote 2 h). Therefore, immunity from external influence was implied but disagreements among development teams were not reported.South Africa adopted IMCI in 1997, originally developed by WHO/UNICEF in the 1990s. IMCI is meant to address serious challenges pertaining to provision of quality child healthcare by focusing on the wellbeing of the whole child . MalnutrThe IMCI guided SAM examination, classification for decision to refer, and stabilisation before and during a transfer; however, the transit instructions were caregiver-centred. The IMCI was clearly for PHC and transit level guidelines.The IMCI scored highly on clarity (87%) and purpose (67%), but low on applicability 38%), rigour of development (24%), stakeholder involvement (17%) and editorial independence (17%). Despite covering PHC and transit recommendations, the IMCI scored the least because its development/adaptation process in South Africa was not reported. Table 8%, rigouScope and purpose: the South Africa version of IMCI lacks an introductory section; thus, its scope and purpose are implicit, but the original version aims to reduce death, illness and disability, and to promote improved health among under-fives [er-fives . Its strStakeholder involvement: we assumed South Africa IMCI abides by WHO requirements which state that all IMCI content should be carefully reviewed and revised (if needed) to make them consistent with the nationally adapted IMCI guidelines [idelines . The IMCRigour of development: procedures for updating the guidelines were not reported. We assumed use of evidence due to guideline sections on clinical warnings about some treatments. Since the IMCI development process could not be easily traced, there was no guarantee about whether the evidence search processes, selection and their limits were rigorously engaged.Clarity of presentation: well-articulated recommendations were arranged in the form of examination (by looking and tests), classification (colour-coded severity) and treatment. Recommendations were also specific and unambiguous with different options for stabilisation and referrals suggested for severe cases.Applicability: South Africa-specific HIV/AIDS needs and evidence of implementation were included (quote 3b). Although not clear in the booklet, IMCI guidelines were adapted to include identification and management of HIV-infected and -exposed children. However, it is unknown whether the SAM treatments are feasible in resource-constrained and rural PHC facilities. Auditing criteria were also absent.Editorial independence: with no report on competing interests and funders, we assumed the South African government was part of the IMCI development/adaptation process funding body. However, it was unknown whether the adaptation team was influenced by the government or WHO/UNICEF .The IMC-SAM is the latest (2015) and only national guideline document entirely dedicated to acute malnutrition in South Africa. The IMC-SAM supplements a two-page national protocol for managing children with SAM (appendix 11 of guideline), which was developed in 2012 .The IMC-SAM covered five steps of the SAM referral process, namely SAM examination, classification, diagnosis/care at hospital, decision to refer back and rehabilitation. IMC-SAM guided hospital and PHC facility practices but had minimal transit instructions. Additionally, IMC-SAM did not strongly stress stabilisation of SAM at PHC level.This document scored the highest of all the appraised documents with both scope and clarity scoring 89%, 74% on stakeholder involvement, 61% on applicability, 54% on rigour and 20% on editorial independence. The guideline followed the format of recent WHO documents and thus had more information on reasons for its development and its objectives. Table Scope and purpose: its objectives were clearly stated; the questions covered by the guideline were stated under sub-headings. It was exceptional since it had ample information on the problem of SAM, ideal SAM care and its goals.Stakeholder involvement: the guidelines clearly acknowledged developers and had well-identified target users. Contributors/developers were the nutrition and child directorate, child health and nutrition experts, international partners and members of the EDL committee. However, it is unknown whether public opinions were sought (quote 4a). Users of the guidelines were identified as doctors, nurses, dietitians and other healthcare workers responsible for the medical, dietary, social and rehabilitative management of SAM [t of SAM .Rigour of development: the guidelines were informed by the 2013 evidence-based SAM care recommendations made in the WHO guidelines update document and the 2008 Lancet series on maternal and child undernutrition [utrition . Concurrutrition . HoweverClarity of presentation: it had specific, easily identifiable and unambiguous recommendations for both diagnosis and treatment of SAM with a diagram guiding decisions to refer at PHC level and treatment routes at hospital level. However, ease of use remained unsatisfactory since there was too much information for easy identification and follow through during implementation at different levels of care.Applicability: Prior to IMC-SAM, there were strong piloting strategies of advocating for grants for all children with SAM and ensuring availability of resources for managing SAM in the Eastern Cape Province pilot site (quote 4c and 4d). The funds for the pilot were provided by those that contributed to the nationwide roll-out of 10 steps. Further, it is unknown whether all recommendations are applicable in resource-limited areas (quote 4d).Editorial independence: publication by the government, support for training and advocacy from other organisations were disclosed. However, it was not transparent whether the organisations influenced the development procedures. Although the conflicts of the guideline development team were not disclosed, the 10 steps of SAM care adaptation revealed some conflicts. Among SAM pioneers, a prescription and care practice debate erupted and was resolved using evidence from research (quote 4e). Yet, the editorial independence seems weak because the influence of funders and competing interests of the IMC-SAM development team were not fully disclosed.All guidelines adequately addressed the seven referral practices. However, transit guidelines are vague since they are only in the IMCI, highly disseminated to facility-based healthcare practitioners and seldom disseminated to paramedics. Figure With guidelines disseminated to a variety of users , little demarcation was made based on qualifications of care providers. For instance, nurses cannot administer some antibiotics without a doctor’s instruction; therefore, it is unclear as to which parts of the guidelines are relevant to a nurse, doctor or dietitian.Overall, all guidelines could be recommended for use with some modification on the stakeholders’ involvement, rigour of development, applicability and editorial independence. The guidelines appraised fell short on monitoring and auditing criteria for implementation such as process, behavioural and health outcome measures, which can shape quality of SAM care provision. A well formulated guideline uses rigorous methods, involves relevant stakeholders, including the public/patients, and discloses funders and their roles as well as competing interests.Overall, all guidelines are recommendable for use at different levels of the SAM referral process. Guidelines must adhere to rigorous development processes, involvement of relevant stakeholders and consider implementation applicability. There is a need to address duplication across two national guideline documents (IMC-SAM and EDL) that currently give similar in-hospital care recommendations. Although presented differently with IMC-SAM incorporating recent methods and the EDL being intensive on drug options, there is a need to move to a standard best practice. However, for specific domains of AGREE, the documents had their own best and poorer practices.Scope, purpose and clarity of presentation: The guidelines have clear objectives and recommendations but lack detail about which profession is responsible for specific guideline contents. Improvement of guidelines by identifying this is apt, especially in hospital settings where a child with SAM is under the care of doctors, nurses, dietitians and social workers.Rigour of development: The IMC-SAM is the most recent (2015) and overall highest scoring amongst guidelines reviewed because it is disease specific, utilised recent evidence and was modelled over the recent WHO guidelines using the AGREE criteria [recent 20 and overcriteria , 24. Onlcriteria .Additionally, the absence of guideline update times is worrying since it leaves no assurance on whether new evidence is being incorporated. For instance, there is a 7-year gap between hospital level EDL revisions. The question on how long it should take for a guideline document to be reviewed remains unclear, with little or no debate.Stakeholder involvement: determining which groups and individuals were relevant in the development process was problematic for all guidelines. To increase endorsement of guidelines, end-users must be incorporated [rporated . Some strporated . Patientrporated . To enharporated , 28.Applicability: The potential of clinical practice guidelines to improve care and outcomes relies on their quality and independence [pendence . In thispendence . The pilEditorial independence: a full disclosure of sources of funding, editorial independence from funders and conflicts among the guideline development teams is necessary in ensuring guideline independence from external forces [l forces . Even inAGREE process: This study followed the procedures of AGREE. Potential bias is reduced by collating the views of several experts. However, we acknowledge a bias towards IMCI and WHO-Steps since there were no views from the developing teams; thus, our critiques are based on outsiders views. Furthermore, as the paper shows, utilising the commentaries of these and other experts provides insight into the meanings of the scores.In conclusion, the guidelines have clear scope and purpose for SAM referral healthcare. The clarity in presentation of care recommendations inform PHC and hospital level practices in the South Africa health system, but is inadequate to inform transit practices. Appraisals have revealed shortcomings in the guidelines development process and some gaps in implementation strategies. However, many SAM guidelines implementation difficulties may not be a result of poor clinical recommendations but of the health systems administrative challenges. These require research so that evidence can aid future guideline development. In the meantime, the IMC-SAM seems the best guideline since it has recent and more comprehensive recommendations.


The objective was to estimate temporal associations between mental disorders and physical diseases in adolescents with mental-physical comorbidities.This article bases upon weighted data (N = 6483) from the National Comorbidity Survey Adolescent Supplement (participant age: 13–18 years), a nationally representative United States cohort. Onset of Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition lifetime mental disorders was assessed with the fully structured World Health Organization Composite International Diagnostic Interview, complemented by parent report. Onset of lifetime medical conditions and doctor-diagnosed diseases was assessed by self-report.The most substantial temporal associations with onset of mental disorders preceding onset of physical diseases included those between affective disorders and arthritis (hazard ratio (HR) = 3.36, 95%-confidence interval (CI) = 1.95 to 5.77) and diseases of the digestive system , between anxiety disorders and skin diseases , and between substance use disorders and seasonal allergies . The most substantial temporal associations with physical diseases preceding mental disorders included those between heart diseases and anxiety disorders , epilepsy and eating disorders , and heart diseases and any mental disorder .Findings suggest that mental disorders are antecedent risk factors of certain physical diseases in early life, but also vice versa. Our results expand the relevance of mental disorders beyond mental to physical health care, and vice versa, supporting the concept of a more integrated mental-physical health care approach, and open new starting points for early disease prevention and better treatments, with relevance for various medical disciplines. Lancet are dealing with the challenges that non-communicable diseases and mental disorders are imposing on the health care systems, and it has been claimed that these conditions need to be considered in global efforts in improvements of health, social policy, and health-care delivery [As the health of young people contributing to future population health and global economic development has been neglected yet, it has now become a ‘pressing issue’ . The Wordelivery –4.The relevance of the integration of mental and physical health arises from adult studies documenting the systematic co-occurrence of mental disorders and physical diseases , 5–10. FDespite this relevance, the understanding of mental-physical comorbidity in children and adolescents is scarce, even though some studies support a relationship between mental disorders and physical diseases already during childhood or adolescence –35. FirsThe current understanding of the etiology of mental-physical comorbidity is largely based on theoretical models attempting to explain how mental disorders and physical diseases come to be comorbid. These theories suppose that one condition operates as risk factor for the other, or that shared risk factors underlie both mental disorders and physical diseases , 40. HowTo better understand the developmental trajectories of mental-physical comorbidity, the main objective of this study was to estimate in adolescents with mental-physical comorbidity the temporal association of mental disorders and physical diseases, using data on the age of onset of a wide range of mental and physical morbidities from a representative national cohort study.We based this study on data of the National Comorbidity Survey Replication Adolescent Supplement (NCS-A), a national representative survey of initially 10148 United States (US) adolescents (ages 13–18), of which 10123 were students at the time of the survey. Data collection took place between February 2001 and January 2004 –45. FurtTo assess lifetime mental disorders, trained interviewers administered a computer-assisted version of the WHO Composite International Diagnostic Interview (CIDI) Version 3.0 , 46; detWe grouped specific mental disorders into the following disorder categories: Any affective disorder , any anxiety disorder , any behavior disorder , any substance use disorder , any eating disorder . If an adolescent, based on either adolescent or parent report, fulfilled diagnostic criteria for more than one disorder with a certain disorder category, we used the earliest age as age of onset of the respective disorder category.The lifetime presence  and the age of onset of physical diseases were assessed solely with adolescent self-report, based on a checklist on chronic conditions, which has been applied in the US National Health Interview Survey in similar form . CheckliPhysical diseases included in our study can be seen in Figs We used weighted data in all statistical analyses, which were conducted with STATA/MP 11 . Weights were provided with the NCS-A dataset, and had been calculated based on a wide range of sociodemographic variables with regard to , 44 to eFor a low number of subjects information on physical diseases from adolescent self-report was missing. We restricted each analysis to subjects with complete data . The most substantial associations included those of heart diseases with any mental disorder and anxiety disorders, and between epilepsy and eating disorders. In support of transparency, results of the crude regression models are presented in We provide information on age of onset intervals between the temporal relations of our most robust findings in This article provides temporal association estimates of lifetime mental disorders and physical diseases, based on data from 6483 adolescents of a nationally representative cohort. The most substantial results indicate that affective disorders are a risk factor of arthritis and diseases of the digestive system, that anxiety disorders are a risk factor of skin diseases, and that substance use disorders are a protective factor of seasonal allergies. Vice versa, heart diseases may indicate a risk of anxiety disorders and any mental disorder, and epilepsy a risk of eating disorders.Our results contribute to previous findings on mental-physical comorbidity mostly resulting from association studies in clinical or population-based samples in adults and documenting comprising relationships between mental disorders and physical diseases , 5, 6, iThere is rare evidence from adult intervention trials providing insight into the developmental trajectories of co-occurring mental disorders and physical diseases. A contribution of depression in arthritis is supported by a study demonstrating benefits of improved depression care that extended beyond reduced depressive symptoms and included decreased pain in older adults with arthritis and comorbid depression . That anIn contrast to findings from meta-analyses of studies in adults , 81, ourDifferent biological, behavioral, cognitive, and social pathways mediating the relationships between mental disorders and physical diseases have been proposed, but even though study designs to inform about developmental trajectories have already been applied successfully , specifiWith regard to depression and arthritis, previous work documents the pain-enhancing potential of brain circuits that may be disturbed in depression  and, vicRegarding depression-related onset of diseases of the digestive system, the pathophysiology of the brain-gut axis, involving the corticotropin-releasing factor system  may playIn terms of potential mechanisms underlying the observed prediction of skin diseases by anxiety disorders, it is of note that psychological stress has not only been associated with atopic dermatitis symptom severity , but alsThe reduced risk of seasonal allergy related to substance use disorders in our study may be a consequence of increased consumption of certain substances, for example alcohol, and related immunological changes –103, butBody perception and interoceptive conditioning may contribute to the heart disease-related increased risk of anxiety disorders : Heartbe"Did a doctor or other health professional ever tell you that you had any of the following illnesses…") might have led to underestimated values, because to positively answer any of these questions the adolescent must have sought a health professional and recalled the diagnosis.Strengths of our study include the large nationally representative sample , the broHowever, a suitable longitudinal dataset allowing studying the chronology of onset of mental disorders and physical diseases in mental-physical comorbidity patterns is lacking while needed to corroborate our findings. Until then, these findings are important to guide future research by providing hypotheses, not least given the novel probing strategy of the National Comorbidity Surveys that has been shown to increase the accuracy of age of onset reports . MoreoveMoreover, according to the risk-factor concept by Kraemer and colleagues  and due Given the high lifetime prevalence of some comorbidity patterns , 35, theA large body of evidence from the WHO World Mental Health Survey documented that the epidemiology of mental-physical comorbidity in adults is comparable worldwide , suggestFuture studies should, besides surveying longitudinal data, include subclinical manifestations of mental disorders and physical diseases, for example using non-invasive measures of arterial structure and function for heart diseases, that occur before the onset of symptoms, in order to better understand the temporal sequence of the relationships. Additionally, it may be worth scrutinizing the comorbidity of mental and physical conditions with regard to the relevance of age of onset, duration of the conditions, and temporal distance between ages of onset (in future studies). Moreover, randomized-controlled intervention trials in representative populations and animal models would be important to shed light on the causality and underlying biological, psychological and behavioral mechanisms of the relationships between mental disorders and physical diseases that we revealed, to foster the development of interdisciplinary preventive approaches and interventions, including the development of clinical guidelines dealing simultaneously with mental disorders and physical diseases .To the best of our knowledge, this is the first comprehensive study of the temporal association of mental disorders and physical diseases in adolescents with mental-physical comorbidity in a nationally representative survey, based on data from 6483 subjects. The most substantial results indicate that affective disorders may increase the risk of arthritis and diseases of the digestive system, that anxiety disorders may increase the risk of skin diseases, and that substance use disorders may decrease the risk of seasonal allergies. Vice versa, heart diseases may indicate a risk of anxiety disorders and any mental disorder, and epilepsy a risk of eating disorders. The clear temporal relationships between mental disorders and physical diseases for specific comorbidity patterns suggest that certain mental disorders may be risk factors of certain physical diseases at early life stages, and vice versa. These results predominantly expand the relevance of mental disorders in adolescence beyond mental health care to physical health care, and vice versa, supporting the concept of integrative care, and open new starting-points for early disease prevention and better treatments, which is relevant for various medical disciplines.S1 Table(XLS)Click here for additional data file.S2 Table(XLS)Click here for additional data file.S3 Table(XLS)Click here for additional data file.S4 Table(XLS)Click here for additional data file.


The FooRecommendations for routine use of vaccines in children, adolescents, and adults are developed by the Advisory Committee on Immunization Practices (ACIP). ACIP is chartered as a federal advisory committee to provide expert external advice and guidance to the Director of the Centers for Disease Control and Prevention (CDC) on use of vaccines and related agents for the control of vaccine-preventable diseases in the civilian population of the United States. Recommendations for routine use of vaccines in children and adolescents are harmonized to the greatest extent possible with recommendations made by the American Academy of Pediatrics (AAP), the American Academy of Family Physicians (AAFP), and the American College of Obstetrics and Gynecology (ACOG). Recommendations for routine use of vaccines in adults are harmonized with recommendations of AAFP, ACOG, and the American College of Physicians (ACP). ACIP recommendations adopted by the CDC Director become agency guidelines on the date published in the Morbidity and Mortality Weekly Report (MMWR). http://www.cdc.gov/vaccines/acip.Additional information regarding ACIP is available at The burden of herpes zoster increases as persons age, with steep increases occurring after age 50 years. Not only does the risk of herpes zoster itself increase with age, but among persons who experience herpes zoster, older persons are much more likely to experience postherpetic neuralgia (PHN) , non-paiMerck is the only U.S. supplier of varicella zoster virus (VZV)-containing vaccines . Beginning in 2007, Merck experienced production shortfalls of the bulk product used to manufacture VZV-based vaccines, leading to intermittent delays in filling of Zostavax orders. As a result of increased production capacity and reliability, by January 2012, Merck had resumed routine supply of varicella-containing vaccines, and Zostavax returned to normal shipping  for the prevention of herpes zoster over a mean follow up period of 1.3 years  , a randoThe long-term persistence study  continueAt the October 2013 meeting, ACIP reviewed results from an updated cost-effectiveness analysis comparing health outcomes, health care resource utilization, costs, and quality-adjusted life years (QALYs) related to herpes zoster, PHN, and non-pain complications among unvaccinated persons and persons vaccinated at either age 50, 60, or 70 years . The modWhat recommendations are being reviewed?Since 2008, the Advisory Committee on Immunization Practices (ACIP) has recommended routine vaccination of all persons aged ≥60 years with 1 dose of herpes zoster vaccine.Why are the recommendations being reviewed now?After approval by the Food and Drug Administration for use of zoster vaccine in adults aged 50 through 59 years in 2011, ACIP initially considered use of the vaccine among adults in this age group, but declined to change its recommendations at that time, citing shortages of Zostavax and limited data on long-term protection afforded by herpes zoster vaccine. A new review was conducted because the manufacturer has resumed routine supply of Zostavax and additional data on long-term protection have become available.What is currently recommended?Considering that the burden of herpes zoster and its complications increases with age and that the duration of vaccine protection in persons aged ≥60 years is uncertain, ACIP’s recommendation remains unchanged; herpes zoster vaccine is routinely recommended only for adults aged ≥60 years.Because the protection offered by the herpes zoster vaccine wanes within the first 5 years after vaccination, and duration of protection beyond 5 years is uncertain, it is unknown to what extent persons vaccinated before age 60 years will be protected as they age and their risk for herpes zoster and its complications increases. Because duration of protection offered by the vaccine is uncertain, the need for revaccination is not clear. Assuming waning of vaccination protection according to currently available studies, the cost-effectiveness model projects a substantially greater reduction of disease burden, health care utilization, and costs with vaccination of older adults who have higher incidence of herpes zoster and related complications. Considering that the burden of herpes zoster and its complications increases with age and that the duration of vaccine protection in persons aged ≥60 years is uncertain, ACIP maintained its current recommendation that herpes zoster vaccine be routinely recommended for adults aged ≥60 years.With FDA approval, Zostavax is available in the United States and indicated for use among adults aged ≥50 years. Vaccination providers considering the use of Zostavax among certain persons aged 50 through 59 years despite the absence of an ACIP recommendation should discuss the risks and benefits of vaccination with their patients. Although the vaccine has short-term efficacy, there have been no long-term studies of vaccine protection in this age group. In adults vaccinated at age ≥60 years, vaccine efficacy wanes within the first 5 years after vaccination, and protection beyond 5 years is uncertain; therefore, adults receiving the vaccine before age 60 years might not be protected when their risks for herpes zoster and its complications are highest. CDC is actively monitoring postmarketing data on duration of vaccine protection in adults vaccinated at age ≥60 years. As additional data become available, ACIP will reevaluate the optimal age for vaccination and the need for revaccination to maintain protection against herpes zoster and its complications.


Few children consume the recommended amount of fruits and vegetables, and schools are a valuable setting for interventions, including programs such as the National School Lunch Program, to increase consumption. Previous research explored factors in this program that influence fruit and vegetable consumption. The objective of this scoping review was to identify, describe, and categorize studies that quantitatively measured the consumption of fruits and vegetables during the school lunch meal among US elementary school students.We conducted a scoping review to identify, describe, and categorize studies examining factors influencing fruit and vegetable consumption during lunch among children in the United States. Eligibility criteria included studies that reported fruit and vegetable consumption at the lunch meal among children in kindergarten through grade 5. We included all types of study designs and categorized factors according to a socioecological framework.We identified 49 studies that examined the influence of one or more factors on elementary students’ consumption of fruits and vegetables. Factors (n = 21) were categorized according to a socioecological framework: individual (3 factors), social environment (3 factors), physical environment (9 factors), policy (2 factors), and a combined approach (4 factors). Several factors had consistent positive associations with fruit and vegetable consumption at lunch across 2 or more studies: increasing age, serving sliced fruits, serving vegetables first, allowing more time for eating, using incentives, using social marketing and/or nutrition education curricula, and using the updated nutrition standards. Only 10 studies used a randomized design.Although we found consistent evidence for some factors, we found conflicting or limited evidence for most, which points to the need for replication in future studies. The lack of randomized designs is a challenge, because it precludes the ability to draw conclusions about cause and effect. Our review may aid in framing practical aspects of the design of future research and in identifying an approach for a systematic review. Every dEating behaviors are complex, resulting from factors across multiple levels of influence. Interest in understanding factors influencing fruit and vegetable consumption at school lunch extend beyond factors regulated by federal policy. A comprehensive mapping of all the interventions or factors that may influence fruit and vegetable consumption at school lunch may be useful for researchers designing interventions with fruit and vegetable consumption as the primary outcome . PreviouThe objective of this scoping review was to identify, describe, and categorize studies that quantitatively measured the consumption of fruits and vegetables during the school lunch meal among elementary school students. A scoping review maps and categorizes all existing literature on a topic to identify areas for further research and/or to commission future targeted systematic reviews . They arPopulation: elementary students in kindergarten through grade 5 in US schoolsIntervention: all intervention types were considered and describedComparator: preintervention versus postintervention, control versus intervention and/or exposed versus unexposed groupsOutcome: fruit and vegetable consumption at the school lunch mealContext: the lunch setting among schools participating in the NSLP from 2004 through January 2017This framework is useful for guiding the search strategy for a review as well as the interpretation of results  and “elementary”. We manually searched the bibliographies of previous reviews –11 and a results .We exported identified records into EndNote, version X5 (Thomson Reuters) and removed duplicates. Both authors reviewed the titles and abstracts of all records. After removing records that did not meet the inclusion criteria, we assessed the full text of the remaining articles against the eligibility criteria. Eligibility criteria included: 1) a US setting, 2) inclusion of students in kindergarten through grade 5, 3) written in English, 4) publication from 2004 through January 2017 , and 5) assessment of the consumption of fruits and vegetables during the lunch meal on a specific day or days . We excluded studies that focused only on middle and high school students because these students were more likely to be exposed to competitive foods, which detract from participation in the NSLP . We alsoWe extracted data from each article on the following factors: setting, study design, sample size (students and schools), type of dietary assessment methodology used, the variable or intervention examined, and results. We considered all supplementary data and referenced publications from each study. Because the aim of our review was to map the existing literature, we did not formally appraise the quality of included studies.We categorized factors according to a socioecological framework ,14. ThisWe screened the titles and abstracts of 3,535 identified studies, reviewed the full-text of 99 studies for eligibility, and deemed 49 studies eligible for further study –64 Tabl. Twenty-The methods used to assess fruit and vegetable consumption varied: 19 studies used weighed plate waste ,58,60,64Studies varied in the operationalization of the dependent variable (fruit and vegetable consumption): 18 studies examined volume  consumed ,59–61,63We found inconsistencies in the definition of fruits and vegetables. Authors of 6 studies ,44,53,57Individual factors. Individual factors included age (5 studies), sex (1 study) and diet quality (3 studies). Five studies examined age , all of which used a cross-sectional design and observed a positive association between age and fruit and vegetable consumption ; verbal prompts (1 study) and item naming (1 study). Three studies examined the use of incentives in the cafeteria to encourage the consumption of fruits and vegetables, one at the group level , portion size (1 study), the order in which food is served (2 studies), dishware type (2 studies), meal preparation/service (4 studies), recess before lunch (4 studies), time for lunch (1 study), time of day (1 study), and access to salad bars or a la carte offerings (2 studies).Two studies examined the effect of serving sliced fruits on students’ consumption and observed positive effects for oranges  but mixeTwo studies examined the dishware used ,35. PhotFour studies examined the order of recess relative to lunch -40,42, tA study of the consumption of food and beverage items when students had access to a la carte snack bars observed decreased consumption of vegetables but not fruit . AnotherCombined factors. All combined approaches showed positive effects on fruit and vegetable consumption  and the updated HHFKA standards (8 studies). Three studies examined the use of default food options (when fruit and vegetable items are provided to students without their having an active choice), and these found mixed results  appeared to be valid for use among school-aged children , with miOur review identified several considerations for the design of future studies that may be useful for those who are tasked with evaluating the effectiveness of similar interventions. First, most studies sampled students from more than one grade. Such sampling may pose a challenge given that age is a factor that determines fruit and vegetable consumption. Researchers who pool data across grades may want to control for age or grade as a covariate. Second, although many studies in our review used a statistical correction for school-level clustering, some did not. The multilevel structure of typical recruitment methods for students  results in student observations that are no longer independent and therefore clustered . A recenAlthough our review has several strengths, including its comprehensiveness and categorization of factors according to the socioecological framework, it has several limitations. First, the studies included were limited to those conducted in elementary schools in the United States. Although potential exists for additional evidence from other countries and among other age groups, the limited scope of our review is useful for researchers designing interventions for the US elementary school population. Second, the focus on the outcome of fruit and vegetable consumption may have obscured potentially synergistic or antagonist effects on other components of the NSLP meal. For example, increased consumption of fruits and vegetables during lunch may also affect consumption of whole-grain foods, which was not accounted for in our review. Because the objective of our review was to map the extent of the literature in this area, future systematic reviews on topic should focus on the factors identified in this framework and appraise quality to understand the strength of the evidence.Although the updated NSLP nutrition standards have increased the availability and consumption of fruits and vegetables, further research is needed to understand factors that influence their consumption by elementary school students. Multiple factors influence this behavior, which makes designing interventions challenging. Researchers may benefit from considering the factors identified in this framework as potential determinants of consumption or as components of interventions. However, the operationalization of fruit and vegetable consumption outcome variables needs to be made consistent in future research. Practitioners and policy makers who are interested in promoting fruit and vegetable consumption can also use the framework described in our review. Several factors were consistently associated with fruit and vegetable consumption across multiple studies. Although future research is needed, there may be immediate opportunities for intervention on these factors in school lunch settings with potential positive effects on the consumption of fruits and vegetables.